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1.  Neighborhood Effects on Youth Substance Use in a Southwestern City 
This study examines neighborhood influences on alcohol, cigarette and marijuana use among a predominantly Latino middle school sample. Drawing on theories of immigrant adaptation and segmented assimilation, we test whether neighborhood immigrant, ethnic, and socioeconomic composition, violent crime, residential instability, and family structure have differential effects on substance use among youth from different ethnic and acculturation backgrounds. Data are drawn from self-reports from 3,721 7th grade students attending 35 Phoenix, Arizona middle schools. Analysis was restricted to the two largest ethnic groups, Latino students of Mexican heritage and non-Hispanic Whites. After adjusting for individual-level characteristics and school- level random effects, only one neighborhood effect was found for the sample overall, an undesirable impact of neighborhood residential instability on recent cigarette use. Sub-group analyses by individual ethnicity and acculturation showed more patterned neighborhood effects. Living in neighborhoods with high proportions of recent immigrants was protective against alcohol, cigarette, and marijuana use for Latino students at different acculturation levels, while living in predominantly Mexican heritage neighborhoods (mostly non-immigrants) was a risk factor for alcohol and marijuana use for less acculturated Latinos. There were scattered effects of neighborhood poverty and crime, which predicted more cigarette and alcohol use, respectively, but only among more acculturated Latinos. Inconsistent effects confined to bilingual and more acculturated Latinos were found for the neighborhood's proportion of single mother families and its residential instability. No neighborhood effects emerged for non-Hispanic White students. Results suggested that disadvantaged neighborhoods increase substance use among some ethnic minority youth, but immigrant enclaves appear to provide countervailing protections.
doi:10.1525/sop.2007.50.2.273
PMCID: PMC3040571  PMID: 21339890
neighborhood effects; substance use; adolescents; Mexican Americans; acculturation
2.  Puerto Rican Early Adolescents’ Self-Esteem Patterns 
This study examines self-esteem as a multidimensional construct in 1 Latino subgroup, Puerto Rican girls and boys during early adolescence, using Harter’s (1985b) Self-Perception Profile for Children. The results show that in its English and Spanish versions—the latter developed by the present research team—the Self-Perception Profile for Children has adequate reliability for use with 13- to 14-year-old Puerto Rican youth living on the mainland. Results obtained in this study of Puerto Rican early adolescents, which contrasts with the results from the combined data of “Hispanics” in the American Association of University Women (1991) survey of 3,000 youth, strongly suggests that Latino subgroups need to be studied separately. The mean levels of self-esteem found among Puerto Rican girls and boys were generally similar to those found among Harter’s sample of predominantly Anglo middle school students from the suburbs of Denver except that Puerto Rican youth did not show gender differences in overall self-esteem. Gender differences in mean levels of self-esteem in different domains were similar to those of Anglo youth, regardless of the Puerto Rican youth’s individual level of psychological or behavioral acculturation. When differences by acculturation emerged, psychological acculturation appeared to play a more protective role for girls (Hispanic- or Latino-oriented girls reported being better behaved and having greater confidence in their scholastic abilities) and behavioral acculturation operated as a risk factor for boys (boys with preference for English reported low Behavioral Conduct and Scholastic Competence scores). On the other hand, greater acculturation (both psychological and behavioral) was associated with girls’ lower confidence in their physical attractiveness. Finally, the structure of self-esteem varied by gender, and psychological and behavioral acculturation.
doi:10.1207/SJRA1003_6
PMCID: PMC3066011  PMID: 21461183
3.  DIFFERENCES BY GENDER, ETHNICITY, AND ACCULTURATION IN THE EFFICACY OF THE keepin’ it REAL MODEL PREVENTION PROGRAM* 
Journal of drug education  2007;37(2):123-144.
This study examined whether the efficacy of keepin’ it REAL, a model program for substance use prevention in schools, was moderated by gender, ethnicity, and acculturation. Gender differences in program efficacy may arise through boys’ higher risk of drug use, inadequate attention to girls’ developmental issues, or cultural factors like polarized gender expectations. Data came from a randomized trial in 35 Phoenix, Arizona, middle schools involving 4,622 mostly Latino 7th graders. Using multi-level mixed models and multiple imputation missing techniques, results for the total sample showed no gender differences in program effects on recent substance use, but the program was more effective in fostering boys’ than girls’ anti-drug norms. Subgroup analyses demonstrated several more beneficial program effects for boys than girls (less alcohol and cigarette use and stronger anti-drug norms), but only among less acculturated Latinos. There were no gender differences in program effects among more acculturated Latinos, nor among non-Latino whites.
PMCID: PMC3838635  PMID: 17977237
4.  Ethnic Pride, Traditional Family Values, and Acculturation in Early Cigarette and Alcohol Use Among Latino Adolescents 
A structural equations model examined the influence of three cultural variables of ethnic pride, traditional family values and acculturation, along with the mediating variables of avoidance self-efficacy and perceptions of the “benefits” of cigarette smoking, on cigarette and alcohol use in a sample of Latino middle school students in the Southwest. Girls (N = 585) and boys (N = 360) were analyzed separately. In both groups, higher ethnic pride and traditional family values exerted indirect effects on less cigarette smoking and alcohol use when mediated through greater self-efficacy and less endorsement of the “benefits” of cigarette smoking. Among the girls, greater ethnic pride also had a direct effect on less cigarette and alcohol use. Also, greater acculturation directly predicted more cigarette and alcohol use among the girls, but not among the boys. However, differences between the boys and girls were generally nonsignificant as revealed by multiple group latent variable models. These results offer implications for incorporating cultural variables into the design of culturally relevant prevention interventions that discourage cigarette and alcohol use among Latino adolescents.
doi:10.1007/s10935-009-0174-z
PMCID: PMC2818880  PMID: 19415497
Ethnic pride; Acculturation; Traditional family values; Latino adolescents; Alcohol use; Tobacco use; Gender differences
5.  Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox 
Social science & medicine (1982)  2005;61(6):1243-1255.
Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES. Results provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified.
doi:10.1016/j.socscimed.2005.01.016
PMCID: PMC3587355  PMID: 15970234
Latino mortality paradox; Smoking; Alcohol use; Exercise; Body mass index; USA
6.  Perceived Ethnic Discrimination versus Acculturation Stress: Influences on Substance Use among Latino Youth in the Southwest* 
Using a predominately Mexican-origin Latino sample of 5th grade students from the Southwestern United States, this study examined the relative effects of perceived discrimination and acculturation stress on substance use, and it assessed whether these effects were moderated by linguistic acculturation or time in the United States. Although rates of substance use were generally low in the sample, given the young age of the participants, over half (59%) of the sample perceived some discrimination, and almost half (47%) experienced some acculturation stress. Spanish-dominant and bilingual youth perceived more discrimination than English-dominant youth, whereas youth who have been in the United States five or fewer years perceived more discrimination than youth with more time in the United States. Youth who were Spanish-dominant or were recent arrivals experienced the most acculturation stress, with levels declining as linguistic acculturation and time in the United States increased. Multiple regression estimates indicated that perceived discrimination was associated with larger amounts and higher frequency of recent substance use and an array of substance use attitudes, such as stronger intentions to use substances, espousal of pro-drug norms, more positive substance use expectancies, and peer approval of substance use. Although acculturation stress was not associated with substance use, it was positively associated with several substance use attitudes, which are known antecedents of actual use. With a few exceptions, linguistic acculturation and time in the United States did not moderate the effects of perceived discrimination or acculturation stress.
PMCID: PMC2821707  PMID: 20099450
7.  Influences of School Latino Composition and Linguistic Acculturation on a Prevention Program for Youth* 
Social work research  2010;34(1):6-19.
This study examined how ethnic composition and linguistic acculturation within schools affected the efficacy of a youth substance use prevention model program. Data come from a randomized trial of the keepin' it REAL program, using a predominantly Mexican American sample of middle school students in Phoenix, Arizona. Schools were randomly assigned to a control group or to one of three culturally tailored intervention versions. We hypothesized that school ethnic and linguistic acculturation composition (percent Latino, percent non-English speaking at home) and individual level of linguistic acculturation jointly would moderate the efficacy of the prevention program, as indicated by students' alcohol, marijuana, and cigarette use. Using multilevel linear modeling and multiple imputation techniques to manage clustered data and attrition, results showed that desired program effects varied by the linguistic acculturation level of the school, the program version, and individual acculturation level. The Latino intervention version was more efficacious in schools with larger percentages of non-English speaking families, but only among less linguistically acculturated Latino students. There were no significant school level program effects connected to the percentage of Latino students at school, the other versions of the program, or among more linguistically acculturated students.
PMCID: PMC2922772  PMID: 20721310
8.  Gender Differences in the Effect of Linguistic Acculturation on Substance Use Among Mexican-Origin Youth in the Southwest United States 
This study tested for gender differences in the impact of linguistic acculturation on pro-drug norms, substance use intentions, and actual substance use among youth of Mexican heritage in a large metropolitan area in the Southwest United States. The authors analyzed baseline survey data provided by 2,487 middle school students of Mexican heritage who were part of a larger, multiethnic randomized efficacy trial of a drug abuse prevention program. Using multi-group structural equation modeling, the authors found that linguistic acculturation was positively and directly related to adherence to pro-drug norms, substance use intentions, and recent alcohol use, controlling for age, poor grades, and socioeconomic status. In addition, linguistic acculturation had an indirect effect on substance use intentions and recent alcohol use through pro-drug norms. The direct effect of linguistic acculturation on pro-drug norms was stronger for girls than for boys, as was its indirect effect on substance use intentions.
doi:10.1080/15332640903539252
PMCID: PMC2903967  PMID: 20390972
acculturation; gender differences; Mexican American youth; substance use; substance use norms
9.  Gender Identity, Ethnicity, Acculturation, and Drug Use: Exploring Differences among Adolescents in the Southwest 
Journal of community psychology  2003;31(2):167-188.
This article presents the findings of a survey completed by 1351 predominantly Mexican American middle school students residing in a large urban center in the U.S. Southwest. The study explores possible associations between drug use attitudes and behaviors and gender (biological sex), gender identity, ethnicity, and acculturation status. Based on the concepts of “machismo” and “marianismo” that have been used to describe Mexican populations, four dimensions of gender identity were measured: aggressive masculinity, assertive masculinity, affective femininity, and submissive femininity. In explaining a variety of indicators of drug use behaviors and anti-drug norms, gender alone had limited explanatory power, while gender identity—often regardless of gender—was a better predictor. Aggressive masculinity was generally associated with higher risk of drug use, while the other three gender identity measures had selected protective effects. However, the impact of gender identity was strongly mediated by acculturation. Less acculturated Mexican American students reported lower aggressive masculinity scores than non-Latinos. Less acculturated Mexican American girls reported both the lowest aggressive masculinity scores and the highest submissive femininity scores. More acculturated Mexican American students, along with the less acculturated Mexican American boys, did not appear to be following a polarized approach to gender identity (machismo and marianismo) as was expected. The findings suggest that some aspects of culturally prescribed gender roles can have a protective effect against drug use behaviors and attitudes, possibly for both girls and boys.
doi:10.1002/jcop.10041
PMCID: PMC3045088  PMID: 21359134
10.  God Forbid! Substance Use Among Religious and Nonreligious Youth 
Among a predominately Mexican and Mexican American sample of preadolescents, religiosity protected against lifetime alcohol, cigarette, and marijuana use and recent alcohol and cigarette use when religious affiliation was controlled. When religiosity was controlled, however, adolescents with no religious affiliation and adolescents who were religiously affiliated reported similar substance use outcomes. Interaction effects demonstrated that the protective effect of greater religiosity operated more strongly in some religions than in others for selected outcomes. Overall, the impact of religiosity on reported drug use did not differ significantly for more and less acculturated Latino youth.
doi:10.1037/0002-9432.75.4.585
PMCID: PMC3043382  PMID: 16262516
adolescents; drug use; religiosity; Mexican American; acculturation
11.  Correlates of self worth and body size dissatisfaction among obese Latino youth 
Body image  2011;8(2):173-178.
The current study examined self-worth and body size dissatisfaction, and their association with maternal acculturation among obese Latino youth enrolled in a community-based obesity intervention program. Upon entry to the program, a sample of 113 participants reported global self-worth comparable to general population norms, but lower athletic competence and perception of physical appearance. Interestingly, body size dissatisfaction was more prevalent among younger respondents. Youth body size dissatisfaction was associated with less acculturated mothers and higher maternal dissatisfaction with their child's body size. By contrast, although global self-worth was significantly related to body dissatisfaction, it was not influenced by mothers’ acculturation or dissatisfaction with their own or their child’s body size. Obesity intervention programs targeted to Latino youth need to address self-worth concerns among the youth as well as addressing maternal dissatisfaction with their children’s body size.
doi:10.1016/j.bodyim.2010.12.002
PMCID: PMC3072832  PMID: 21354881
self-worth; body size dissatisfaction; acculturation; obese Latino youth
12.  Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States 
General Hospital Psychiatry  2012;34(4):323-331.
Objective
Physical symptoms are common and a leading reason for primary care visits, however data are lacking on their prevalence among racial/ethnic minorities in the United States. This study aimed to compare the prevalence of physical symptoms among White, Latino, and Asian Americans, and examine the association of symptoms and acculturation.
Methods
We analyzed data from the National Latino and Asian American Study, a nationally-representative survey of 4864 White, Latino, and Asian Americans adults. We compared the age- and gender-adjusted prevalence of fourteen physical symptoms among the racial/ethnic groups and estimated the association between indicators of acculturation (English proficiency, nativity, generational status, and proportion of lifetime in the United States) and symptoms among Latino and Asian Americans.
Results
After adjusting for age and gender, the mean number of symptoms was similar for Whites (1.00) and Latinos (0.95) but significantly lower among Asian-Americans (0.60, p < 0.01 versus Whites). Similar percentages of Whites (15.4%) and Latinos (13.0%) reported 3 or more symptoms, whereas significantly fewer Asian-Americans (7.7%, p<0.05 versus Whites) did. In models adjusted for sociodemographic variables and clinical status (psychological distress, medical conditions, and disability), acculturation was significantly associated with physical symptoms among both Latino and Asian Americans, such that the most acculturated individuals had the most physical symptoms.
Conclusions
The prevalence of physical symptoms differs across racial/ethnic groups, with Asian Americans reporting fewer symptoms than Whites. Consistent with a ‘healthy immigrant’ effect, increased acculturation was strongly associated with greater symptom burden among both Latino and Asian Americans.
doi:10.1016/j.genhosppsych.2012.02.007
PMCID: PMC3383871  PMID: 22460006
Acculturation; Asian Americans; Epidemiology; Hispanic Americans; Signs and Symptoms
13.  Experimenting with cigarettes and physical activity among Mexican origin youth: a cross sectional analysis of the interdependent associations among sensation seeking, acculturation, and gender 
BMC Public Health  2012;12:332.
Background
Sensation seeking tendencies tend to manifest during adolescence and are associated with both health-compromising behaviors and health-enhancing behaviors. The purpose of this study is to evaluate the relationship between sensation seeking and physical activity, a health-enhancing behavior, and between sensation seeking and experimenting with cigarettes, a health compromising-behavior, among a cohort of Mexican origin adolescents residing in the United States with different levels of acculturation.
Methods
In 2009, 1,154 Mexican origin youth (50.5% girls, mean age 14.3 years (SD = 1.04)) provided data on smoking behavior, physical activity, linguistic acculturation, and sensation seeking. We conducted Pearson’s χ2 tests to examine the associations between categorical demographic characteristics (i.e. gender, age, country of birth and parental educational attainment) and both cigarette experimentation and physical activity and Student’s t-tests to examine mean differences on the continuous variables (i.e. sensation seeking subscale) by the behaviors. We examined mean differences in the demographic characteristics, acculturation, and both behaviors for each of the sensation seeking subscales using analysis of variance (ANOVA). To examine relationships between the sensation seeking subscales, gender, and both behaviors, at different levels of acculturation we completed unconditional logistic regression analyses stratified by level of acculturation.
Results
Overall, 23.3% had experimented with cigarettes and 29.0% reported being physically active for at least 60 minutes/day on at least 5 days/week. Experimenting with cigarettes and being physically active were more prevalent among boys than girls. Among girls, higher levels of sensation seeking tendencies were associated with higher levels of acculturation and experimentation with cigarettes, but not with physical activity. Among boys, higher levels of sensation seeking tendencies were associated with higher levels of acculturation, experimenting with cigarettes and being physically active.
Conclusions
Our results suggest that interventions designed to prevent smoking among Mexican origin youth may need to address social aspects associated with acculturation, paying close attention to gendered manifestations of sensation seeking.
doi:10.1186/1471-2458-12-332
PMCID: PMC3441442  PMID: 22559717
Smoking behavior; Physical activity; Acculturation; Sensation seeking; Gender; Mexican origin youth
14.  Overweight in Young Latino Children 
Archives of medical research  2008;39(5):511-518.
Background
Acculturation status is associated with overweight and obesity among Latino adults, but the relationship between maternal acculturation and overweight in Latino children is inconsistent and has not been adequately studied.
Methods
We analyzed 3-year follow-up data from 185 Latina mothers and children who were recruited at San Francisco General Hospital. Outcome measure was the child’s body mass index at age 3 years, adjusted for age and sex and categorized as healthy (<85%) or overweight (≥85%). Independent variables were maternal acculturation status, child health status, and child nutritional factors.
Results
At age 3 years, 43% of children were overweight. In multivariate logistic regression analyses, childhood overweight was associated with maternal acculturation status (adjusted odds ratio [OR] 1.99, 95% confidence interval [95% CI] 1.07–3.69) and maternal obesity (OR 3.71, 95% CI 1.40–9.84). Childhood overweight was also more likely among children who were reported to eat well or very well (OR 3.33, 95% CI 1.46–7.58) and children whose weight was perceived as too high (OR 11.88, 95% CI 2.37–59.60), as compared to children who were reported to eat poorly/not well and children whose weight was perceived as normal, respectively.
Conclusions
Interventions to reduce the high rates of overweight among young Latino children should address the importance of maternal acculturation and obesity as well as maternal perceptions of children’s weight and eating habits.
doi:10.1016/j.arcmed.2008.02.008
PMCID: PMC2519869  PMID: 18514096
Obesity; Overweight; Child; Preschool; Hispanic Americans; Mexican Americans
15.  Majority Rules? The Effects of School Ethnic Composition on Substance Use by Mexican Heritage Adolescents* 
Sociological focus  2004;37(4):371-392.
This article examines key aspects of the school environment — its composition by ethnicity and acculturation — as important social contexts for understanding Mexican immigrant and Mexican American adolescents' drug use norms and behaviors. Results are presented based on surveys completed by Mexican-background students from 35 Phoenix. Arizona middle schools, whose enrollment ranged from a numerical minority to an overwhelming majority. Multivariate mixed models tested for the influence of school ethnic composition measures on substance use outcomes, while accounting for individual level predictors and for the nesting of data at the school level. The proportional representation of Latinos in the school was not a factor in an individual's drug use norms or drug use for the sample overall. Once students were broken down by acculturation status, however, ethnic composition had an effect. Less acculturated Mexican heritage students in schools with higher proportions of Latino students reported less substance use and less adherence to pro-drug norms. Further investigation using other measures of ethnic composition suggested that these effects were attributable to the larger presence of less acculturated Latinos in the school rather than more acculturated Latino students. These school-level effects support the individual-level results indicating that less acculturated Mexican American students face less daunting substance use risks. The results suggest that ethnic group size, but not necessarily numerical predominance, matters and that within-group differences influence the effect of a particular ethnic group's presence in the school. In other words, the majority does not always rule. These findings are interpreted using the concepts of segmented assimilation and school level social capital.
PMCID: PMC3113510  PMID: 21686029
16.  The Effects of Parental Acculturation and Parenting Practices on the Substance Use of Mexican-Heritage Adolescents from Southwestern Mexican Neighborhoods 
A sample of 189 Mexican-heritage seventh grade adolescents reported their substance use, while one of the child’s parents reported parent’s acculturation and communication, involvement, and positive parenting with his or her child. Higher levels of parental acculturation predicted greater marijuana use, whereas parent communication predicted lower cigarette and marijuana use among girls. A significant parent acculturation by parent communication interaction for cigarette use was due to parent communication being highly negatively associated with marijuana use for high acculturated parents, with attenuated effects for low acculturated parents. A significant child gender by parent acculturation by parent positive parenting interaction was found. For girls, positive parenting had a stronger association with lower cigarette use for high acculturated parents. For boys, positive parenting had a stronger association with reduced cigarette use for low acculturated parents. Discussion focuses on how acculturation and gender impact family processes among Mexican-heritage adolescents.
doi:10.1080/15332640.2014.905215
PMCID: PMC4206522  PMID: 25176121
acculturation; Mexican American adolescents; parenting; substance use
17.  HIV risk behaviors and sociodemographic features of HIV-infected Latinos residing in a new Latino settlement area in the Southeastern United States 
AIDS care  2013;25(10):1298-1307.
The Southeastern United States (US) has a rapidly growing Latino population, yet little is known about HIV-infected Latinos in the region. To help inform future prevention studies, we compared sociodemographic, clinical, and behavioral characteristics between immigrant and US-born HIV-infected Latinos using face-to-face interviews conducted at three clinics in North Carolina. Questions encompassed HIV testing, acculturation, sexual- and substance-related behaviors, and migration history. Behavioral data were compared with 451 black and white clinic patients. Differences were tested using Pearson’s and Kruskal–Wallis tests. Participants (n = 127) were primarily male (74%) and immigrants (82%). Most immigrants were Mexican (67%), had low acculturation scores (92%), and were diagnosed a median of 8 years (IQR 0–12) following immigration. Compared with US-born Latinos, immigrants had lower CD4 counts at clinic entry (median 187 vs. 371 cells/mm3) and were less likely to have graduated high school (49% vs. 78%) or have insurance (9% vs. 52%; all P < 0.05). Most immigrants identified as heterosexual (60%) and reported fewer lifetime partners than US-born Latinos (median 6 vs. 20; P = 0.001). Immigrant men were less likely to report sex with men than US-born men (43% vs. 81%; P = 0.005). Immigrant men also had similar risk behaviors to black men, and US-born Latino men exhibited behaviors that were more similar to white men in our clinic. At the time of survey, >90% of participants were receiving antiretroviral therapy (ART) and most had achieved HIV RNA <50 copies/mL (62% immigrants vs. 76% US-born; P = 0.32). In conclusion, Latino immigrants were more likely to present with advanced disease, identify as heterosexual, and report different risk behaviors than US-born Latinos, yet receipt and response to ART were similar between the two groups. Prevention strategies should prioritize finding innovative methods to reach Latino immigrants for routine early testing regardless of risk stratification and include programs targeted toward the different needs of immigrant and US-born Latinos.
doi:10.1080/09540121.2013.764964
PMCID: PMC4125118  PMID: 23384328
Hispanic; HIV; CD4 lymphocyte count; Southeast United States; immigrants
18.  Acculturation, Gender, Depression, and Cigarette Smoking Among U.S. Hispanic Youth: The Mediating Role of Perceived Discrimination 
Journal of youth and adolescence  2011;40(11):1519-1533.
Hispanic youth are at risk for experiencing depressive symptoms and smoking cigarettes, and risk for depressive symptoms and cigarette use increase as Hispanic youth acculturate to U.S. culture. The mechanism by which acculturation leads to symptoms of depression and cigarette smoking is not well understood. The present study examined whether perceived discrimination explained the associations of acculturation with depressive symptoms and cigarette smoking among 1,124 Hispanic youth (54% female). Youth in Southern California completed surveys in 9th–11th grade. Separate analyses by gender showed that perceived discrimination explained the relationship between acculturation and depressive symptoms for girls only. There was also evidence that discrimination explained the relationship between acculturation and cigarette smoking among girls, but the effect was only marginally significant. Acculturation was associated with depressive symptoms and smoking among girls only. Perceived discrimination predicted depressive symptoms in both genders, and discrimination was positively associated with cigarette smoking for girls but not boys. These results support the notion that, although Hispanic boys and girls experience acculturation and discrimination, their mental health and smoking behaviors are differentially affected by these experiences. Moreover, the results indicate that acculturation, gender, and discrimination are important factors to consider when addressing Hispanic youth’s mental health and substance use behaviors.
doi:10.1007/s10964-011-9633-y
PMCID: PMC3753367  PMID: 21293915
Acculturation; Gender; Perceived discrimination; Depression; Cigarette smoking; Hispanic youth
19.  Decomposing associations between acculturation and drinking in Mexican Americans 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1111/j.1530-0277.2011.01712.x
PMCID: PMC3349785  PMID: 22316139
Mexican Americans; Acculturation
20.  Bullying Victimization as a Mediator of Associations between Cultural/familial Variables, Substance use and Depressive symptoms among Hispanic Youth 
Ethnicity & health  2013;18(4):415-432.
Objectives
This article examines the antecedents and consequences of bullying victimization among a sample of Hispanic high school students. Although cultural and familial variables have been examined as potential risk or protective factors for substance use and depression, previous studies have not examined the role of peer victimization in these processes. We evaluated a conceptual model in which cultural and familial factors influenced the risk of victimization, which in turn influenced the risk of substance use and depression.
Design
Data were collected as part of a longitudinal survey study of 9th and 10th grade Hispanic/Latino students in Southern California (n=1167). The student bodies were at least 70% Hispanic/Latino with a range of socioeconomic characteristics represented. We used linear and logistic regression models to test hypothesized relationships between cultural and familial factors and depression and substance and a meditational model to assess whether bullying victimization mediated these associations.
Results
Acculturative stress and family cohesion were significantly associated with bullying victimization. Family cohesion was associated with depression and substance use. Social support was associated with alcohol use. Acculturative stress was associated with higher depression. The associations between acculturative stress and depression, family cohesion and depression, and family cohesion and cigarette use were mediated by bullying victimization.
Conclusion
These findings provide valuable information to the growing, but still limited, literature about the cultural barriers and strengths that are intrinsic to the transition from adolescence to emerging adulthood among Hispanic youth. Our findings are consistent with a mediational model in which cultural/familial factors influence the risk of peer victimization, which in turn influences depressive symptoms and smoking, suggesting the potential positive benefits of school based programs that facilitate the development of coping skills for students experiencing cultural and familial stressors.
doi:10.1080/13557858.2012.754407
PMCID: PMC3723765  PMID: 23297708
Hispanic; acculturation; family cohesion; bullying victimization; depression; substance use
21.  The Influence of Linguistic Acculturation and Gender on the Initiation of Substance Use Among Mexican Heritage Preadolescents in the Borderlands 
The Journal of early adolescence  2011;31(2):271-299.
This article examined the impact of linguistic acculturation and gender on the substance use initiation of a sample of 1,473 Mexican heritage preadolescents attending 30 public schools in Phoenix, Arizona. It was hypothesized that linguistic acculturation operates differently as a risk or protective factor for young children than for older youth. The study used discrete-time event history methods to model the rate at which nonusing children initiate substance use. Alcohol, cigarettes, marijuana, and inhalants were studied separately while inhalant use was examined more closely. Results suggested that while linguistic acculturation is a risk factor for Mexican heritage preadolescents, this association depended on gender, the linguistic acculturation context (family, friends, or media), and the type of substance. For inhalants, higher linguistic acculturation with friends was inversely associated with drug initiation both for boys and girls. Implications for preventive science and future intervention research are discussed.
doi:10.1177/0272431610363157
PMCID: PMC3108799  PMID: 21660121
acculturation; bilingual/bicultural; Hispanic/Latino/Latina; substance use/alcohol and drug use
22.  Acculturation, Coping Styles, and Health Risk Behaviors Among HIV Positive Latinas 
AIDS and behavior  2010;14(2):401-409.
This study examined the relationships among acculturation, coping styles, substance use, sexual risk behavior, and medication non-adherence among 219 Latinas living with HIV/AIDS in Los Angeles, CA. Coping styles were hypothesized to mediate the link between acculturation and health risk behaviors for HIV positive Latinas. Structural equation modeling revealed that greater acculturation was related to less positive coping and more negative coping. In turn, negative coping was associated with more health risk behaviors and more non-adherence. Positive coping was associated with less substance use as reflected in use of cigarettes and alcohol and less non-adherence. Coping styles mediated the relationship between acculturation and health risk behaviors. Findings echo previous works examining the Hispanic Health Paradox wherein more acculturated Latinos exhibit increased risk behavior and maladaptive coping styles. HIV/AIDS interventions need to be mindful of cultural differences within Hispanic populations and be tailored to address these differences.
doi:10.1007/s10461-009-9618-y
PMCID: PMC2835805  PMID: 19847637
Acculturation; Coping styles; Latinas; HIV/AIDS; Hispanic
23.  School Context and Individual Acculturation: How School Composition Affects Latino Students’ Acculturation* 
Sociological inquiry  2012;82(3):460-484.
Understanding how schools—a key context for children—shape students’ cultural trajectories is important since these trajectories are tied to youth development and achievement. This study assessed how the size of the school’s group of acculturated Latino and non-Latino students influenced the acculturation of 1,720 Latino 5th-grade students from urban public schools in the Southwest United States. A longitudinal secondary data analysis revealed that controlling for wave 1 acculturation, youths in schools with larger proportions of linguistically acculturated students were more acculturated at wave 2 than youths in schools with smaller proportions of such students. This effect was independent of Latino students’ baseline acculturation level and was found even in schools with minority proportions of more acculturated students.
doi:10.1111/j.1475-682X.2012.00423.x
PMCID: PMC3519394  PMID: 23239897
24.  Acculturation and the Prevalence of Diabetes in US Latino Adults, National Health and Nutrition Examination Survey 2007–2010 
Introduction
US Latinos are growing at the fastest rate of any racial/ethnic group in the United States and have the highest lifetime risk of diabetes. Acculturation may increase the risk of diabetes among all Latinos, but this hypothesis has not been studied in a nationally representative sample. The objective of this study was to test the hypothesis that acculturation was associated with an increased risk of diabetes in such a sample.
Methods
We conducted a cross-sectional analysis including 3,165 Latino participants in the 2007–2010 National Health and Nutrition Examination Survey. Participants with doctor-diagnosed diabetes and participants without diagnosed diabetes who had glycated hemoglobin (HbA1C) values of 6.5% or higher were classified as having diabetes. An acculturation score, ranging from 0 (lowest) to 3 (highest), was calculated by giving 1 point for each of 3 characteristics: being born in the United States, speaking predominantly English, and living in the United States for 20 years or more. Logistic regression was used to determine the association between acculturation and diabetes.
Results
The prevalence of diabetes among Latinos in our sample was 12.4%. After adjusting for sociodemographic factors, the likelihood of diabetes (95% confidence interval [CI]) increased with level of acculturation— 1.71 (95% CI, 1.31–2.23), 1.63 (95% CI, 1.11–2.39), and 2.05 (95% CI, 1.27–3.29) for scores of 1, 2, and 3, respectively. This association persisted after further adjustment for body mass index (BMI), total dietary calories, and physical inactivity.
Conclusion
Acculturation was associated with a higher risk of diabetes among US Latinos, and this risk was only partly explained by BMI and weight-related behaviors. Future research should examine the bio-behavioral mechanisms that underlie the relationship between acculturation and diabetes in Latinos.
doi:10.5888/pcd11.140142
PMCID: PMC4193061  PMID: 25299982
25.  Heart Disease and Stroke Statistics—2011 Update 
Circulation  2010;123(4):e18-e209.
Summary
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.
Death Rates From CVD Have Declined, Yet the Burden of Disease Remains High
The 2007 overall death rate from CVD (International Classification of Diseases 10, I00–I99) was 251.2 per 100 000. The rates were 294.0 per 100 000 for white males, 405.9 per 100 000 for black males, 205.7 per 100 000 for white females, and 286.1 per 100 000 for black females. From 1997 to 2007, the death rate from CVD declined 27.8%. Mortality data for 2007 show that CVD (I00–I99; Q20–Q28) accounted for 33.6% (813 804) of all 2 243 712 deaths in 2007, or 1 of every 2.9 deaths in the United States.
On the basis of 2007 mortality rate data, more than 2200 Americans die of CVD each day, an average of 1 death every 39 seconds. More than 150 000 Americans killed by CVD (I00–I99) in 2007 were <65 years of age. In 2007, nearly 33% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years.
Coronary heart disease caused ≈1 of every 6 deaths in the United States in 2007. Coronary heart disease mortality in 2007 was 406 351. Each year, an estimated 785 000 Americans will have a new coronary attack, and ≈470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent first myocardial infarctions occur each year. Approximately every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.
Each year, ≈795 000 people experience a new or recurrent stroke. Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks. Mortality data from 2007 indicate that stroke accounted for ≈1 of every 18 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke. From 1997 to 2007, the stroke death rate fell 44.8%, and the actual number of stroke deaths declined 14.7%.
In 2007, 1 in 9 death certificates (277 193 deaths) in the United States mentioned heart failure.
Prevalence and Control of Traditional Risk Factors Remains an Issue for Many Americans
Data from the National Health and Nutrition Examination Survey (NHANES) 2005–2008 indicate that 33.5% of US adults ≥20 years of age have hypertension (Table 7-1). This amounts to an estimated 76 400 000 US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. African American adults have among the highest rates of hypertension in the world, at 44%. Among hypertensive adults, ≈80% are aware of their condition, 71% are using antihypertensive medication, and only 48% of those aware that they have hypertension have their condition controlled.
Despite 4 decades of progress, in 2008, among Americans ≥18 years of age, 23.1% of men and 18.3% of women continued to be cigarette smokers. In 2009, 19.5% of students in grades 9 through 12 reported current tobacco use. The percentage of the nonsmoking population with detectable serum cotinine (indicating exposure to secondhand smoke) was 46.4% in 1999 to 2004, with declines occurring, and was highest for those 4 to 11 years of age (60.5%) and those 12 to 19 years of age (55.4%).
An estimated 33 600 000 adults ≥20 years of age have total serum cholesterol levels ≥240 mg/dL, with a prevalence of 15.0% (Table 13-1).
In 2008, an estimated 18 300 000 Americans had diagnosed diabetes mellitus, representing 8.0% of the adult population. An additional 7 100 000 had undiagnosed diabetes mellitus, and 36.8% had prediabetes, with abnormal fasting glucose levels. African Americans, Mexican Americans, Hispanic/Latino individuals, and other ethnic minorities bear a strikingly disproportionate burden of diabetes mellitus in the United States (Table 16-1).
The 2011 Update Expands Data Coverage of the Obesity Epidemic and Its Antecedents and Consequences
The estimated prevalence of overweight and obesity in US adults (≥20 years of age) is 149 300 000, which represents 67.3% of this group in 2008. Fully 33.7% of US adults are obese (body mass index ≥30 kg/m2). Men and women of all race/ethnic groups in the population are affected by the epidemic of overweight and obesity (Table 15-1).
Among children 2 to 19 years of age, 31.9% are overweight and obese (which represents 23 500 000 children), and 16.3% are obese (12 000 000 children). Mexican American boys and girls and African American girls are disproportionately affected. Over the past 3 decades, the prevalence of obesity in children 6 to 11 years of age has increased from ≈4% to more than 20%.
Obesity (body mass index ≥30 kg/m2) is associated with marked excess mortality in the US population. Even more notable is the excess morbidity associated with overweight and obesity in terms of risk factor development and incidence of diabetes mellitus, CVD end points (including coronary heart disease, stroke, and heart failure), and numerous other health conditions, including asthma, cancer, degenerative joint disease, and many others.
The prevalence of diabetes mellitus is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity.
On the basis of NHANES 2003–2006 data, the age-adjusted prevalence of metabolic syndrome, a cluster of major cardiovascular risk factors related to overweight/obesity and insulin resistance, is 34% (35.1% among men and 32.6% among women).
The proportion of youth (≤18 years of age) who report engaging in no regular physical activity is high, and the proportion increases with age. In 2007, among adolescents in grades 9 through 12, 29.9% of girls and 17.0% of boys reported that they had not engaged in 60 minutes of moderate-to-vigorous physical activity, defined as any activity that increased heart rate or breathing rate, even once in the previous 7 days, despite recommendations that children engage in such activity ≥5 days per week.
Thirty-six percent of adults reported engaging in no vigorous activity (activity that causes heavy sweating and a large increase in breathing or heart rate).
Data from NHANES indicate that between 1971 and 2004, average total energy consumption among US adults increased by 22% in women (from 1542 to 1886 kcal/d) and by 10% in men (from 2450 to 2693 kcal/d; see Chart 19-1).
The increases in calories consumed during this time period are attributable primarily to greater average carbohydrate intake, in particular, of starches, refined grains, and sugars. Other specific changes related to increased caloric intake in the United States include larger portion sizes, greater food quantity and calories per meal, and increased consumption of sugar-sweetened beverages, snacks, commercially prepared (especially fast food) meals, and higher energy-density foods.
The 2011 Update Provides Critical Data Regarding Cardiovascular Quality of Care, Procedure Utilization, and Costs
In light of the current national focus on healthcare utilization, costs, and quality, it is critical to monitor and understand the magnitude of healthcare delivery and costs, as well as the quality of healthcare delivery, related to CVDs. The Update provides these critical data in several sections.
Quality-of-Care Metrics for CVDs
Chapter 20 reviews many metrics related to the quality of care delivered to patients with CVDs, as well as healthcare disparities. In particular, quality data are available from the AHA’s “Get With The Guidelines” programs for coronary artery disease and heart failure and the American Stroke Association/ AHA’s “Get With the Guidelines” program for acute stroke. Similar data from the Veterans Healthcare Administration, national Medicare and Medicaid data and National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network - “Get With The Guidelines” Registry data are also reviewed. These data show impressive adherence with guideline recommendations for many, but not all, metrics of quality of care for these hospitalized patients. Data are also reviewed on screening for cardiovascular risk factor levels and control.
Cardiovascular Procedure Utilization and Costs
Chapter 21 provides data on trends and current usage of cardiovascular surgical and invasive procedures. For example, the total number of inpatient cardiovascular operations and procedures increased 27%, from 5 382 000 in 1997 to 6 846 000 in 2007 (National Heart, Lung, and Blood Institute computation based on National Center for Health Statistics annual data).
Chapter 22 reviews current estimates of direct and indirect healthcare costs related to CVDs, stroke, and related conditions using Medical Expenditure Panel Survey data. The total direct and indirect cost of CVD and stroke in the United States for 2007 is estimated to be $286 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medications, home health care, and other medical durables) and lost productivity resulting from mortality (indirect costs). By comparison, in 2008, the estimated cost of all cancer and benign neoplasms was $228 billion ($93 billion in direct costs, $19 billion in morbidity indirect costs, and $116 billion in mortality indirect costs). CVD costs more than any other diagnostic group.
The AHA, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current data available in the Statistics Update. The 2007 mortality data have been released. More information can be found at the National Center for Health Statistics Web site, http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf.
Finally, it must be noted that this annual Statistical Update is the product of an entire year’s worth of effort by dedicated professionals, volunteer physicians and scientists, and outstanding AHA staff members, without whom publication of this valuable resource would be impossible. Their contributions are gratefully acknowledged. Véronique L. Roger, MD, MPH, FAHAMelanie B. Turner, MPHOn behalf of the American Heart Association Heart Disease and Stroke Statistics Writing Group
Note: Population data used in the compilation of NHANES prevalence estimates is for the latest year of the NHANES survey being used. Extrapolations for NHANES prevalence estimates are based on the census resident population for 2008 because this is the most recent year of NHANES data used in the Statistical Update.
doi:10.1161/CIR.0b013e3182009701
PMCID: PMC4418670  PMID: 21160056
AHA Statistical Update; cardiovascular diseases; epidemiology; risk factors; statistics; stroke

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