Acculturation and Health: State of The Field and Recommended Directions

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Acculturation and Health: State of the Field and Recommended Directions
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DOI: 10.1093/oxfordhb/9780190215217.013.1
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Oxford Handbooks Online

Acculturation and Health: State of the Field and
Recommended Directions
Seth J. Schwartz and Jennifer Unger
The Oxford Handbook of Acculturation and Health
Edited by Seth J. Schwartz and Jennifer Unger
Subject: Psychology, Health Psychology Online Publication Date: Jan 2017

DOI: 10.1093/oxfordhb/9780190215217.013.1
Abstract and Keywords
The purpose of this book is to bridge “basic” theory and research on acculturation—that
is, what acculturation is, how it operates, and what are the appropriate methods to study
it—with “applied” acculturation research—that is, how acculturation affects various
health behaviors and outcomes among migrant populations. This introductory chapter
reviews current theory and research on acculturation and health and points to future
directions for the field. We also propose some new ideas to help move the field forward.
The chapter also lays out the structure of and goals for the book. Fundamental
definitional issues regarding what acculturation is, and how it could relate to health
outcomes, are covered.
Keywords: acculturation, health, measurement, immigrant, research, outcome
International migration has been ongoing for thousands of years. Individuals and groups
have moved in search of food, shelter, safety, prosperity, and land, among many other
motivations (Rystad, 1992). Empires expanded and contracted, climates changed, and
food sources shifted—often requiring people to migrate from one place to another. When
colonial powers such Britain, France, Portugal, the Netherlands, and Spain established
new territories, individuals from the “mother country” were permitted—and sometimes
encouraged—to relocate to the colonized territories (Elliott, 2006).
International migration has become a recognized topic of study primarily in the time
since national borders have been established throughout nearly the entire inhabited
world. The widespread study of migration began with a focus on Europeans migrating to
the United States (Park, 1928). A common theme in the migration literature is that
migrants rarely came in small numbers. Rather, groups tended to migrate in waves, such
as the Irish in the 18th and 19th centuries, the Scandinavians and Germans in the 19th
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century, and eastern and southern Europeans in the late 19th and early 20th centuries
(Steiner, 2009; Sterba, 2003). So, as others (e.g., Deaux, 2006) have observed,
international migration is largely an intergroup phenomenon—a theme that we address
later in this chapter, and that Bourhis and Montreuil cover in depth in their chapter in
this volume.
What Is Acculturation?
When migrating individuals and groups come into contact with individuals from the
receiving cultural context, a process of cultural change ensues. This process has
generally been referred to as acculturation (Redfield, Linton, & Herskovits, 1936).
Although both migrant individuals and individuals from the receiving society are assumed
to change as a result of intercultural contact between the migrant and receiving groups,
most social-science and health-science studies have focused on indicators of cultural
change among individual migrants (Berry, this volume; Rudmin, this volume). However, it
is entirely possible to study acculturation among the migrant group (e.g., at the
sociological level; Kivisto, 2001), to study the transactions between migrants and
members of the receiving society (Rohmann, Florack, & Piontkowski, 2006), or to study
changes in the receiving society as a result of contact with migrants and migrant groups
(Brubaker, 2001).
Even within approaches focused largely on adaptation among individual migrants, there
is no clearly agreed-on definition of acculturation (Rudmin, 2003, 2009, this volume).
Acculturation has been operationalized in a number of different ways—perhaps so many
that the meaning of the construct is not clear (Hunt, Schneider, & Comer, 2004). Among
the most important issues at stake within and across the various operationalizations of
acculturation have been (1) What is it that changes as a result of acculturation? (2) Is
there only one component that changes, or are there multiple components that change?
(3) What creates or precipitates the changes that represent acculturation? and (4) How
do the processes that represent acculturation affect health-related outcomes? The various
theories and operationalizations of acculturation (e.g., Berry, 1997, this volume; Bourhis
& Montreuil, this volume; Gordon, 1964; Ward & Rana-Deuba, 1999) differ across some
or all of these issues. For example, Gordon (1964) and other assimilation theorists
believed that migrants proceed along a linear continuum from “completely
unacculturated” (i.e., attached to their heritage cultural traditions and not to the
receiving culture) to “completely acculturated” (vice versa). An implicit assumption
underlying assimilation models is that someone can hold only a certain “amount” of
culture at once—such that acquiring the receiving cultural stream would cause the
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person to discard the heritage cultural stream to a corresponding extent. Phinney (2003)
and others have referred to this assumption as “culture shedding” and have criticized it
on the grounds that it represents a zero-sum system where acculturation involves
replacing one culture with another, rather than adding a new cultural stream to one’s
existing cultural repertoire.
Most contemporary theories of acculturation (e.g., Berry, this volume; Ward & Kus, 2012)
acknowledge that receiving-culture acquisition and heritage-culture retention represent
separate dimensions of acculturation. That is, whether or not a given migrant adopts
cultural behaviors, values, or identifications reflective of her/his new country does not
dictate whether she/he will retain behaviors, values, or identifications reflective of her/his
country of origin.
Some models have gone even further and have proposed that acculturation can consist of
three or more intersecting cultural streams (e.g., Doucerain, Dere, & Ryder, 2013;
Ferguson & Bornstein, 2013). Indeed, as Schwartz, Birman, Benet-Martínez, and Unger
(this volume) discuss, acculturation can be an especially complex process when migrants
come from minority groups in their countries or regions of origin (e.g., Russian Jews,
Indo-Caribbeans), when the receiving country or region is home to multiple cultural
streams (e.g., Quebec, Switzerland, Belgium), or when pancultural identities (such as
Islam among Middle Eastern, North African, and South Asian migrants to Europe and
North America) are present among migrant groups. In some cases, hybrid cultures can
emerge within a destination culture—such as Chicano culture in the southwestern United
States (Sanchez, 1995).
What emerges from this brief exposition into the definition of acculturation is an
impression that the construct is far more complex and multidimensional than
assimilationist theories (and perhaps even bidimensional theories that distinguish
heritage-culture retention from receiving-culture acquisition) suggest. Given the rapid
diversification occurring in most immigrant-receiving societies, where second-generation
migrants constitute a growing proportion of the population, the assumption that migrants
are acculturating to a single receiving cultural stream is increasingly untenable (van
Oudenhoven & Ward, 2013). Indeed, the concept of segmented assimilation (Portes &
Rumbaut, 2014) suggests that migrant groups are likely to acculturate toward the
receiving-society subgroups to which they are most phenotypically or culturally similar.
For example, Ferguson and Bornstein (2013) have found that Jamaican immigrants to the
United States are most likely to acculturate toward an African American, rather than
White American, cultural stream by virtue of their phenotypic similarity to African
Americans. There are clearly more “moving parts” within the construct of acculturation
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than can be accommodated within a simplistic theoretical approach (Rudmin, 2003, 2009,
this volume).
So what is acculturation, and how would we go about studying it? Clearly one must make
choices regarding which components of acculturation are relevant to a given study
(Doucerain, Segalowitz, & Ryder, this volume). For example, if we are studying effects of
acculturation on health outcomes, we may be most interested in changes occurring
within the individual migrant, rather than in intergroup processes that underlie
acculturative change. What is essential is that we define what we mean by acculturation
and choose measures and methods that are faithful to that definition (Ward, Poortinga, &
Milfont, this volume). That is, it is essential to specify what we believe is changing as a
result of acculturation and assess it accordingly.
Specifying and Operationalizing Meanings of

Acculturation
It is essential to operationalize acculturation in a way that reflects the lived experiences
of the migrants being studied. There may be some instances where a bidimensional
model matches migrants’ experiences—such as Han Chinese or Hindu Gujaratis (who are
the majority ethnic groups in their respective countries) migrating to a largely
monocultural US community. In multicultural urban areas, there are likely to be many
cultural streams to which migrants are exposed—including hybrid cultures that have
developed at the intersection of migrant and destination cultures (Doucerain et al., 2013).
Given that many migrants are bicultural and endorse components of both their heritage
and receiving cultural streams (and perhaps other cultural streams as well),
unidimensional “culture shedding” models would likely not apply in many cases—if they
apply in any cases at all. Unidimensional models may provide misleading results and
conclusions, as we note in the next section.
It is also essential that researchers put forth—or draw explicitly on—a theoretical
approach that specifies the components of acculturation and how they are expected to
interrelate. We provide two examples here—Schwartz et al.’s (Schwartz, Unger,
Zamboanga, & Szapoczni, 2010) bidimensional, multicomponent model and Ward’s (2001)
affect-behavior-cognition (ABC) model. Each of these models specifies not only that
acculturation can be subdivided into heritage- and receiving-cultural dimensions but also
that there are multiple domains that change as a result of acculturation. Both models
include practices or behaviors (e.g., language use, food choices, friend and partner
selection) as an acculturation domain. Schwartz et al. add values and identifications,
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where values refer to one’s emphasis on individualistic and/or collectivistic belief systems
and identifications refer to a sense of attachment to and solidarity with one’s heritage or
ethnic group, the receiving society, or both. Ward adds cognition and affect, where
cognition refers to social identity processes (e.g., identification with the heritage and
receiving cultural groups, similar to ethnic identity) and affect refers to emotional
outcomes (e.g., self-esteem, depressive symptoms) of the acculturation process. These
outcomes might be expanded to include physical health, as is the focus of much of the
present volume.
Within the Schwartz et al. (2010) model, acculturation is defined in terms of six separate
components—heritage-culture practices, heritage-culture values, heritage-culture
identifications, receiving-culture practices, receiving-culture values, and receiving-
culture identifications. Within the context of Hispanic individuals and groups migrating to
the United States, for instance, examples of these components include English language
use and consuming US foods (receiving-cultural practices), endorsing individualist and
independent belief systems (receiving-cultural values), identifying with the United States
(receiving-cultural identifications), Spanish language use and consuming foods from the
country of origin (heritage-cultural practices), endorsing collectivist and familistic values
(heritage-cultural values), and maintaining a sense of ethnic affirmation and pride
(heritage-cultural identifications). These components may or may not change in tandem
(Schwartz et al., 2015) and predict health outcomes in different ways (Schwartz et al.,
2014). This model suggests that acculturation is not a singular variable, and that
individuals cannot be described as “more acculturated” or “less acculturated.” Indeed, a
person may be highly ethnically identified but not be fluent in the language of her or his
heritage country (Portes & Rumbaut, 2014). Such a person’s “level of acculturation”
would depend on the specific domain—in this case practices or identifications—under
consideration.
A further issue to be considered is the types of migrants being studied or referred to.
There are at least four types of migrants (Steiner, 2009)—voluntary immigrants,
refugees, asylum seekers, and sojourners. Voluntary immigrants are people who choose
to migrate from one country to another for any of a number of reasons, including
economic advancement, family reunification, or better lives for their children. Refugees
are individuals who are involuntarily displaced from their homelands by wars or natural
disasters, and who are resettled in another country with the help of international aid
agencies. Asylum seekers are people who leave their homelands under threat of
persecution or harm, and who must apply for admission into another country. Sojourners
are individuals who migrate to another country on a temporary basis for work, studies, or
another specific purpose.
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It stands to reason that acculturation would proceed differently for these different groups
of migrants (Steiner, 2009). Refugees and asylum seekers have often experienced
traumatic events in their homelands, such as fearing for their lives or watching family
members be killed, that may increase the difficulty involved in adjusting to residing in a
new country (Weine et al., 2004). Sojourners generally know that they are not staying
permanently in the country where they are living, so their investment in incorporating
the destination culture into their sense of self may be limited (Smith & Khawaja, 2011).
Further, there may be considerable variations within these broad categories. For
example, when families immigrate with children, the adults are generally the ones who
decide that the family is moving. Children may experience a profound sense of loss upon
being uprooted from their friends and extended family networks (Suárez-Orozco, Suárez-
Orozco, & Todorova, 2009). Refugees also might experience conflicting emotions because
they might have preferred to stay in their home country, but political conditions made
doing so intolerable. There is also a critical demarcation between legal and
undocumented immigration, where undocumented immigrants face far greater stress in
their adaptation process than legal immigrants do (Cobb, Xie, Meca, & Schwartz, in
press). So acculturation is likely experienced quite differently across “types” of migrants,
as well as across generations.
Other variations across individuals, such as ethnicity and socioeconomic status, must also
be considered. As Rudmin (2003) notes, the “difficulty” involved in acculturation is, at
least to some extent, a function of the distance and dissimilarity between or among the
cultures involved. For example, an English-speaking Canadian moving to the United
States would likely have little acculturating to do, given the linguistic and cultural
similarities between Canada and the United States. On the other hand, someone moving
to the United States from rural Mexico would face a far greater challenge given contrast
between the largely collectivist cultural context of rural Mexico and the primarily
individualist cultural context characteristic of the United States, as well as discrimination
from members of US society. The acculturation challenge is also greater for individuals
from low socioeconomic status backgrounds and from visible-minority groups (Beiser,
2005; Steiner, 2009). Low-income migrants are less likely to have access to resources to
help them adjust to their new environment, more likely to reside in unsafe and/or
underresourced communities, and more likely to have to work multiple jobs to meet their
expenses (Portes & Rumbaut, 2014). Individuals from ethnic minority groups may be
more likely to be stereotyped as “foreigners,” assumed to be undocumented, and/or to be
insulted and/or demeaned because of their ethnic and national background, even after
they have adjusted to their new homeland (Lee, Lee, & Tran, this volume).
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Acculturation as an Intergroup Process

As Bourhis and Montreuil (this volume), as well as others (e.g., Schwartz, Vignoles,
Brown, & Zagefka, 2014) have noted, acculturation operates according to intergroup
processes outlined within social psychological theories. One such premise is that the
attitudes of “host nationals” (people from nonmigrant families within the receiving
society) tend to be more negative during times of heavy immigration, and during difficult
economic times, and that individuals from large migrant groups—or those labeled as
“threatening”—are most likely to be rejected and scorned (Coenders, Lubbers,
Scheepers, & Verkuyten, 2008). For the most part, “threatening” migrant groups are
those that share a common identity, such as language or religion, that are viewed as
potentially undermining the identity, safety, or economic viability of the receiving society.
For example, most Hispanic migrants to the United States share Spanish as a common
heritage language, and many North African, Middle Eastern, and South Asian migrants to
Europe share Islam as a common religious background. Some Americans view Spanish
(among other immigrant languages) as undermining the hegemony of English as the US
national language (Buchanan, 2006; Huntington, 2004). Similarly, some Europeans view
Islam as a threat to the largely secular, post-Christian environment in Europe (Bawer,
2004; Bleich, 2009). These specific immigrant groups are likely to serve as the targets of
anti-immigrant backlash in the United States and Europe, respectively. For example,
Hispanics are at the center of US immigration debates, to the point where political
discourse has centered around amnesty versus deportation—and where political
movements have arisen around the issue of keeping undocumented Hispanics out of the
country (and at least one major-party presidential candidate has endorsed this position;
Chavez, 2013). Similarly, in Europe, in many cases Muslims have received a “cold
shoulder” reception and have been stereotyped as terrorists (Caldwell, 2008). For
example, Brüβ (2008) surveyed large samples of Bangladeshi Muslims in London, Turkish
Muslims in Berlin, and Moroccan Muslims in Madrid. He found that many of these people
reported being verbally harassed or otherwise disrespected on a regular basis. Further,
Adida, Laitin, and Valfort (2010) found that, in France, Muslims are less than half as
likely as non-Muslims to receive a callback for a job interview.
A primary social-psychological contribution to the study of acculturation is the framing of

acculturation as an interactive process, where migrants’ preferences are contrasted with
the preferences of receiving-society individuals. Bourhis and Montreuil (this volume)
review much of this literature in their chapter. Briefly, the acculturation process may
proceed most smoothly when migrants are interacting with their new homelands in ways
that match the expectations of receiving-society individuals (Rohmann et al., 2006). For
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example, Canada is generally considered to be highly multicultural, in that migrants are

encouraged to retain their cultural heritage and to integrate that heritage with aspects of
Canadian culture (Berry, 2006). On the contrary, the Netherlands has been regarded as
more assimilationist, where migrants are expected to adopt Dutch cultural values and
behaviors—at least publicly (Vasta, 2007). The United States is likely situated somewhere
in between, with competing social and political discourses regarding the need to protect
the British-European roots of American culture versus the need to incorporate new
cultural streams into the national fabric (Portes & Rumbaut, 2014; Suárez-Orozco et al.,
2009). So migrants to Canada might be more favorably received if they publicly retain
their cultural heritage than might migrants to the Netherlands or to the United States.
Social-psychological research indicates that migrants are likely to be viewed unfavorably

when they are perceived as a threat. Integrated threat theory (Stephan & Stephan, 2000)
puts forth three general types of threats—symbolic threats, realistic threats, and negative
stereotypes. Symbolic threats represent perceived dangers to the solidarity of the
ingroup—such as the belief among some Americans that mass Hispanic migration to the
United States will displace English as the national language (Huntington, 2004). Realistic
threats represent beliefs that migrants will take away jobs and other opportunities that
rightfully belong to host nationals. Research indicates that realistic threats are quite
prominent in the discourse regarding illegal immigration, especially among low-income
individuals who perceive undocumented immigrants as competition for jobs (Chavez,
2013). Negative stereotypes refer to ideas that are held regarding “prototypical”
members of a given group. With specific reference to migrants, stereotypes might refer to
ways in which members of migrant groups are viewed as a drain on the larger society, as
invaders or terrorists who aim to destroy the fabric of the nation, and as criminals who
seek to harm or kill host nationals. For example, Hispanic migrants in the United States
may be stereotyped as illegal-immigrant invaders who are looking to return the US
Southwest to Mexico (Buchanan, 2006), and Muslim migrants to parts of Europe and the
United States may be stereotyped as terrorists whose goal is to destroy Western society
(Caldwell, 2008). Stephan, Renfro, Esses, Stephan, and Martin (2005) found that
receiving-society members who endorsed at least two of these threat types regarding a
fictitious migrant group were most likely to hold negative attitudes regarding that
migrant group. Additionally, ethnic minority migrants are more likely to be viewed
negatively than are those from the same ethnic group as the majority of host nationals
(Lee et al., this volume; Stephan et al., 2005).
In many migration contexts, especially those involving mass migration, all three threat
types are operating simultaneously. For example, consider the case of Mexican migration
to the United States. Mexicans have been migrating to the United States for more than
two centuries, and much of the U. Southwest once belonged to Mexico. Especially since
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1965, Mexicans have migrated to the United States in large numbers, primarily in search
of work (Henderson, 2011). The majority of these migrants have not committed person or
property crimes—and, in fact, there is evidence that foreign-born US residents are less
likely to commit crimes compared with individuals born in the United States (Salas-
Wright, Vaughn, Schwartz, & Córdova, 2016). However, there has been strong anti-
immigrant rhetoric, especially against Mexicans and individuals from other Hispanic
countries, and some writers have argued that Homeland Security provisions intended to
combat terrorism have instead been used against Hispanics (Golash-Boza, 2012). It is
quite possible that these trends have been, at least in part, the results of a confluence of
symbolic threats, realistic threats, and negative stereotypes vis-à-vis Hispanic migrants.
We use these intergroup processes both (1) to illustrate the interactive character of the
acculturation process and (2) to depict the complexity involved in acculturation. Indeed,
it can be argued that acculturation is an interaction between migrants and the
sociocultural contexts in which they have settled, rather than a property of the migrants
themselves, and that studying acculturation as an individual-level construct leaves out
much of the complexity and intricacy underlying the acculturation experience. For
example, consider a scenario where migrants from the same place of origin settle either
in New York City or in rural Kansas. The acculturative experiences for these migrants are
likely to be quite different, even if the migrants had many of the same experiences in the
country of origin. An interactive, intergroup understanding of acculturation is necessary
to understand these people’s lived experiences and, ultimately, the effects of those
experiences on life and health outcomes.
Acculturation and Health Outcomes

The focus of the present volume is not only on acculturation per se, but also on the
effects of acculturative processes on health outcomes. That is, we seek to bridge “basic”
theory and research on acculturation—that is, what acculturation is, how it operates, and
what are the appropriate methods to study it—with “applied” acculturation research—
that is, how acculturation affects various health behaviors and outcomes among migrant
populations. These two streams of literature have adopted quite different methodological
approaches, and by extension, their theoretical underpinnings deviate considerably from
one another. One of our primary goals for the present volume is to connect (or reconnect)
these streams of literature with one another.
The vast majority of studies linking acculturation to health outcomes have used
unidimensional understandings of acculturation (see Abraído-Lanza, Armbrister, Flórez,
& Aguirre, 2006; Suinn, 2010, for reviews). Many of these studies have been based on
Page 9 of 26

secondary analyses of large epidemiological datasets with only a few questions or items
devoted to acculturation. Indeed, in many cases, demographic variables, such as
birthplace (native-born versus foreign-born), years spent in the receiving country, or
language selected to complete the survey are used as markers of acculturation (e.g.,
Padilla et al., 2011; Yang, Chung, Kim, Bianchi, & Song, 2007). When validated scales are
used in clinical or epidemiological studies, these scales often focus primarily—or only—on
language use as a marker of acculturation (e.g., Echeverria & Carrasquillo, 2006).
Indeed, a major challenge in clinical and epidemiological studies, which constitute a

sizable proportion of the health-related research literature, involves (1) participant time
and burden and (2) the need to include a range of constructs on a survey to facilitate
secondary data analyses, thus restricting the number of items that can be devoted to any
one construct. The complexity of acculturation, as reviewed earlier in this chapter and as
covered within several chapters in this volume (e.g., Berry; Rudmin; Ward et al.), does
not mesh well with the challenges and limitations involved in designing clinical and
epidemiological studies. So an important question involves what the most optimal
solution might be—a point to which we return shortly.
Unintended Consequences of Measuring Acculturation Using

Unidimensional or Marker Measures
First, we believe it is important to discuss some of the “unintended consequences” of

measuring acculturation in a way that is not consistent with the theory underlying the
construct, nor with the lived experience of migrants themselves. First, the assumption
that being born in the receiving country, or having lived there for a longer period of time,
represents “greater acculturation” may not be accurate. How much cultural change takes
place over time, or across generations, depends on the setting in which the acculturation
is occurring. For example, Schwartz, Pantin, Sullivan, Prado, and Szapocznik (2006)
found that, for Hispanic adults who had migrated to highly dense ethnic enclaves and had
not attended formal schooling in the United States, the number of years spent in the
United States was not correlated with scores on measures of behavioral acculturation.
Someone who has lived in the receiving country for 10 years, within a setting that
involved a great deal of contact with host nationals, might therefore have undergone
more acculturation than someone who has resided in an ethnic enclave for 30 or 40
years.
In terms of birthplace, Portes and Rumbaut (2014) use the term “1.5 generation” to refer
to individuals who arrived in the receiving country as babies or young children. Although
these people are foreign-born, they are likely more culturally similar to their native-born
counterparts than to individuals who migrated at older ages. Indeed, Portes and Rumbaut
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(2001) present examples of Asian Americans who arrived in the United States as young
children and who were not fluent in their heritage languages. Such individuals are more
similar to US-born Asian Americans, many of whom are not proficient in their heritage
languages, than to Asian Americans who migrated as adolescents or as adults.
Another issue is return migration, where individuals and families may move back and
forth between the origin and destination countries before finally settling in one or the
other (Dustmann, 2003). Return migration may occur by choice, such as when migrants
find jobs in their countries of origin and return there for some period of time—often bring
with them children who had been born in the receiving country. Return migration may
also occur through deportation, where undocumented immigrants are arrested and sent
home—sometimes migrating again some time later (Zayas, 2015). In some cases,
deported individuals may also bring with them children who were born in the receiving
country, and who may return to that country later on (Golash-Boza, 2012).
Using birthplace as a marker of acculturation does not attend to the age at which the
person arrived in the receiving country, or to the possibility that a native-born individual
may have lived in her/his family’s country of origin for some period of time. It may be
advisable to ask foreign-born respondents how old they were when they arrived in the
receiving country, and whether (and for how long) they had returned to live in their
country of origin after the initial migration.
Language use, although it is certainly a component of acculturation, may not map onto
the complexity inherent in the acculturation construct. First, Kang (2006) has found that
language use is empirically distinguishable from other cultural practices (e.g., food, peer
associations). As Portes and Rumbaut (2001) reported regarding a number of Asian
Americans in their sample, the fact that someone cannot speak her or his heritage
language does not mean that that person does not engage in other heritage-cultural
behaviors. Second, language use may not be closely related to other dimensions of
acculturation such as values and identifications. Individuals may identify with their
cultural heritage or endorse heritage-cultural values even if they cannot speak the
associated language—or perhaps they may be fluent in the language but not identify with
their cultures of origin or endorse the values associated with that cultural stream.
Perhaps the most serious limitation involved in using markers of acculturation, or relying
on language use measures, is that the markers are almost always unidimensional—and
language use measures are often unidimensional. Markers such as birthplace or years
spent in the receiving country suggest that greater exposure to the receiving cultural
stream (i.e., having been born there or having spent more of one’s life there) equals
greater “acculturation.” These markers carry the same problems as the unidimensional
constructs that they represent—namely that it is impossible to separate receiving-culture
Page 11 of 26

acquisition from receiving-culture retention. That is, in the event that being born in the
receiving country, or having spent more of one’s life there, is associated with greater risk
for a given health condition, does this indicate that the putative risk factor is increased
endorsement of the receiving cultural stream or that the problem is decreased retention
of one’s cultural heritage? It is impossible to tell, and as a result, the practical import of
health-related studies using unidimensional measures (or markers for them) is limited.
For example, the subtitle for a recent edited volume (García Coll & Marks, 2012) reads
“Is becoming American a developmental risk?” This example is reflective of a public
health phenomenon known as the immigrant paradox (see Alcántara & Alegría, this
volume), where migrants enter the receiving country with better health than the native-
born population—but the migrants’ health deteriorates over years (and across
generations) to converge with, and perhaps become even worse than, that of host
nationals. The immigrant paradox has been observed in a number of migrant-receiving
countries, including the United States (Antecol & Bedard, 2006), Canada (Beiser, 2005),
and Belgium (Lorant, van Oyen, & Thomas, 2008). What is not known, however, is
whether the paradox results from acquiring receiving-cultural practices, values, and
identifications (i.e., the receiving culture makes people sick) or whether the paradox
results from loss of heritage-cultural practices, values, and identifications (i.e., the
heritage culture keeps people healthy). These are two very different public health
messages, and the intervention implications are entirely different. Should we aim to keep
migrants away from receiving-cultural influences (if that is possible), or should we
encourage them to retain their cultural heritage? Recent work using bidimensional and
multidimensional models of acculturation suggests that heritage-culture loss is the
primary mechanism underlying the immigrant paradox (e.g., Schwartz et al., 2016).
Potential Solutions to the Measurement of Acculturation in Health-

Related Studies
Clearly, the complexity of acculturation—involving multiple cultural streams, multiple

domains, and interplay between migrant group and receiving context—is difficult to
capture in a clinical or epidemiological study where participant time and survey space
are limited. However, there may be ways to incorporate more of the complexity of
acculturation than has generally been done in many health-based studies.
First, it is critical to at least measure receiving-culture acquisition and heritage-culture

retention as separate dimensions. Even if shortened scales are used, it is essential to
avoid unidimensional measures that conflate adopting the receiving culture with
relinquishing one’s cultural heritage. The practice of using demographic variables—which
Page 12 of 26

are an additional step removed from construct-valid indices of acculturation—to index

acculturative processes is highly questionable and should be avoided.
One possible approach is to use single items to index each acculturation component that
the researchers wish to assess. For example, to decide which item to use for each
component, one might conduct a confirmatory factor analysis using existing data from a
full acculturation scale, and take the highest loading item. This type of procedure has
been used to select items for daily diary studies (Meca, Schwartz, Stephens, & Szabo,
2016). For example, one item might be selected for use of the receiving-society language,
one for engagement in other receiving-cultural practices, one for receiving-cultural
values, and one for receiving-cultural (national) identity. Analogous items could be
selected for heritage-cultural components. Regardless of the specific items that are used,
the items must map directly onto the acculturation components that are hypothesized to
exist. That is, the measurement approach should match the way in which acculturation
has been operationally defined.
Because acculturation represents an interplay between migrants and their social-cultural

contexts, where possible participants should be sampled from multiple geographic
locations (e.g., Schwartz et al., 2015). For example, one location might be a major city
and the other location might be a smaller community, or multiple cities might be selected
where the cities differ on important demographic and contextual variables (e.g., region of
the country, national origins from which the majority of migrants originate). Multiple
sites provide an internal replication and help to ensure that findings from a single
location are not “reified.” Indeed, specific geographic areas have specific contexts of
reception, political histories, and migration patterns that are likely to affect how migrants
acculturate (Schwartz et al., 2010).
Given that acculturation is, by definition, a longitudinal phenomenon, where possible

multiple time points should be included, Berry (1997) and others have described
acculturation as a pattern of adaptation, suggesting that it involves change over time.
Further, the trajectory of acculturative change—in addition to initial levels of
acculturation—are important predictors of health outcomes among migrants (Schwartz et
al., 2016). Indeed, predictive effects of acculturation on health outcomes can be most
rigorously modeled when prior levels of the outcomes can be statistically controlled—
therefore ensuring that stability in the outcome is factored out of the predictive effect
(Cole & Maxwell, 2003).
Page 13 of 26

Description of and Goals for the Present

Volume
As mentioned earlier, the primary goal of the present volume is to bring together basic
theorizing and research on acculturation with applied research on acculturation and
health outcomes. Accordingly, the book consists of three general sections—(1) basic
principles, (2) links with health outcomes, and (3) intervention development and
refinement. Many of the chapters in the basic principles section do not focus on specific
migrant groups or receiving societies (although some chapters do, especially those
targeted toward cultural stressors). The health outcomes and intervention sections of the
book focus primarily on Hispanic migrants in the United States, for two primary reasons.
First, US Hispanics are among the most commonly studied groups in acculturation
research (Yoon, Langrehr, & Ong, 2011) and are the most commonly studied group in
acculturation-health research (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista,
2005). Second, Hispanics in the United States represent an example of a primarily
collectivist-oriented group migrating to a primarily individualist-oriented society. Much of
the developed world—North America, western Europe, Oceania, and Israel—has been
receiving migrants from the developing world for more than 50 years—and Hispanics in
the United States may be representative of the cultural interplay that occurs in much of
the developed world.
Generally speaking, the first section of the book, in contrast to the second and third
sections of the book, represent the two primary streams of acculturation literature that
have been largely disconnected from one another. Most basic acculturation theory and
research is situated in social science disciplines such as psychology and sociology and
does not target public health outcomes—whereas the majority of health-related research
involving acculturation is situated in public health or medicine and does not capitalize on
newer developments in basic acculturation theory and research (Abraído-Lanza et al.,
2006; Salant & Lauderdale, 2003; Thomson & Hoffman-Goetz, 2009). Our goal is to
facilitate a “meeting of the minds” between these two streams of literature.
The third section of the book includes chapters on the role of culture and acculturation in
intervention design and adaptation. Indeed, cultural considerations in intervention
research represent an important direction in prevention science (Castro, Barrera, &
Holleran Steiker, 2010). We also include one chapter (Bacallao & Smokowski, this
volume) evaluating an intervention specifically designed to promote biculturalism among
migrant adolescents and their parents. The design of such interventions, which represent
one of the first attempts to directly manipulate acculturative processes, are also an
exciting new direction in prevention science.
Page 14 of 26

Section 1: Basic Acculturation Theory and

Research
In chapter 2, John Berry reviews the history of acculturation theory and research and
provides updates to his theorizing. He focuses not only on the four acculturation
categories, for which he is well known, but also on corresponding expectations on the
part of the receiving society and on the ways in which migrants’ approaches to
acculturation may fit (or not fit) with the receiving society’s expectations.
In chapter 3, Seth Schwartz, Dina Birman, Verónica Benet-Martínez, and Jennifer Unger
review the construct of biculturalism and its extensions, including triculturalism and
bicultural identity integration. In particular, Schwartz et al. outline the specific types of
contexts in which biculturalism may be more versus less adaptive, and they suggest
future directions for theory and research on biculturalism and its extensions.
In chapter 4, Richard Bourhis and Annie Montreuil explore the dynamic interactions
between migrants’ acculturation approaches and the ways in which receiving-society
individuals would like migrants to acculturate. Bourhis and Montreuil also review the
construct of bilingual healthcare and the ways in which multilingual societies such as
Canada offer healthcare to individuals with differing language preferences (including
migrants to these societies). They conclude with recommendations for the intersection
between acculturative match/mismatch and provision of healthcare services.
In chapter 5, Floyd Rudmin, Bo Wang, and Joaquim de Castro outline criticisms and
alternative directions for acculturation theory and research. They question the
fundamental assumptions and ideologies underlying acculturation research and suggest
alternative methodologies and approaches for studying acculturation. They also call for
greater attention to within-country migration and to a range of receiving countries that
have garnered little attention in the literature thus far.
In chapter 6, Marina Doucerain, Norman Segalowitz, and Andrew Ryder review and
outline measurement approaches for studying acculturation. They discuss self-report
scales that have been widely used, and they also suggest methods that move beyond self-
reports. Innovative behavioral and biological approaches to measuring acculturation are
proposed and reviewed.
In chapter 7, Andrea Romero and Brandy Piña-Watson review the conceptualization and
measurement of acculturative and bicultural stress among migrant adolescents and
young adults. They outline the ways in which stressors often accompany the acculturation
process, and the ways in which these stressors impact migrants’ psychological,
Page 15 of 26

behavioral, and health outcomes. Romero and Piña-Watson also suggest ways to improve
the tools used to measure acculturative and bicultural stress.
In chapter 8, Richard Cervantes and Thuy Bui adopt a life-domain perspective on

culturally related stressors among Hispanic adults in the United States. Whereas many
other theoretical perspectives and measurement instruments have characterized
acculturative/cultural stress as an overall construct, Cervantes and Bui argue that
specific domains of stress—such as immigration-related stress, acculturation
discrepancies between or among family members, and experiences of discrimination may
be especially harmful vis-à-vis mental and physical health outcomes among adult
Hispanics. The chapter concludes with proposed future directions for developing a more
nuanced understanding of culturally related stressors.
In chapter 9, Joyce Lee, Richard Lee, and Alisia Tran discuss the construct of foreigner
objectification—which occurs when individuals from visible-minority groups are labeled
as “foreign” even if they were born and raised in the receiving country or have mastered
its language and cultural stream. For example, many Asian Americans, and some
Hispanic Americans, may be asked “Where are you really from?” even if they say that
they were born or raised somewhere in the United States. Lee et al. review research
indicating that foreigner objectification is harmful to mental health and may also
interfere with physical health and with seeking healthcare services.
In chapter 10, Gail Ferguson, Steve Tran, Shawn Mendez, and Fons van de Vijver discuss
the construct of remote acculturation, where individuals are exposed to—and adopt—
aspects of foreign cultures to which they have never been directly exposed. That is,
remote acculturation refers to acculturation through globalization rather than through
international migration. Mental health profiles of various remote acculturation
configurations are discussed, along with the effects of remote acculturation on family
relationships and differences in effects of remote acculturation across the various areas
of the world in which this phenomenon has been studied.
In chapter 11, Colleen Ward, Ype Poortinga, and Taciano Milfont review methods for
conducting cross-cultural research studies. Issues such as sampling, measurement
equivalence, and consideration of local contexts are discussed. Ward et al. pay particular
attention to the differences between epidemiological and social-behavioral studies and
outline the different types of goals that these broad categories of research projects are
designed to accomplish within the auspices of cross-cultural comparative work. Broadly,
this chapter is a “how-to” regarding conducting cross-cultural research.
Page 16 of 26

Section 2: Associations Between Acculturation

and Health Outcomes
In chapter 12, Carmela Alcántara, Cindy Estevez, and Margarita Alegría discuss the
immigrant paradox, whereby recent migrants appear to be healthier than longer-term
migrants and whereby first-generation migrants appear to be healthier than later-
generation migrants. In their extensive review of the literature, Alcántara et al. conclude
that the paradox is likely an oversimplification, in that patterns of health outcomes across
migrant status and length of stay vary across migrant nationality, age at the time of
migration, and the specific health outcomes examined. They also review methodological
effects that might help to account for the paradox.
In chapter 13, Carolina Hausmann-Stabile and Luis Zayas report the results of a
qualitative study on suicidality among young, urban Hispanic women in the United
States. Hausmann-Stabile and Zayas stress that disconnection from family and
acculturation to “street culture” represent key risk factors for suicidality among these
young women. These authors propose recommendations for suicide prevention efforts
targeted toward young, urban, women from low-income migrant backgrounds.
In chapter 14, Miguel Pinedo, Sarah Zemore, Cheryl Cherpitel, and Raul Caetano review
the links between acculturative processes and alcohol use among Hispanic adults in the
United States. They also report the results of a study examining acculturation and alcohol
use in border and nonborder regions. Broadly, Pinedo et al. report that links between
acculturation and alcohol use disorders differed between border and nonborder contexts.
Specifically, in border regions, Hispanic women who were more proficient in English also
were at greater risk for alcohol problems. Pinedo et al. frame their discussion around
differences in alcohol use norms for women between the United States and Mexico—and
they call for greater specificity and context-sensitivity in acculturation-alcohol use
research.
In chapter 15, Byron Zamboanga, Cara Tomaso, and Priscilla Lui discuss links between
acculturation and alcohol use among Hispanic and Asian college students in the United
States. Zamboanga et al. note that many studies in this area have used unidimensional
measures that do not permit disentangling of the effects of US-culture-acquisition from
the effects of heritage-culture loss. They highlight the inconsistencies in the
acculturation–alcohol use literature among college students and propose directions for
future work. In many ways, the recommendations offered by Zamboanga et al. are similar
to those offered by Pinedo et al.—suggesting that many of the same limitations
Page 17 of 26

characterize the acculturation–alcohol use literatures among college students and among
other subgroups of adults.
In chapter 16, Alan Meca, Lauren Reinke, and Lawrence Scheier review what is known
regarding the associations of acculturation with cigarette and illicit drug use. Similar to
what Zamboanga et al. found in their review of the college student acculturation–alcohol
use literature, the majority of published studies on acculturation and cigarettes/illicit
drugs used unidimensional operationalizations and measures of acculturation. Meca et al.
offer suggestions for advancing and strengthening this literature.
In chapter 17, Jennifer Tsai and her colleagues provide a review of research on
acculturation and sexual behavior among Hispanic and Asian individuals in the United
States. Tsai et al. synthesize often-contradictory findings and report that links between
acculturation and sexual behavior vary across migrant group, nativity (US-born versus
foreign-born), gender, and the specific type of sexual behavior under consideration. Tsai
et al. suggest a number of avenues for future work, as well as avenues for intervention
development and refinement.
In chapter 18, Paul Smokowski, Martica Bacallao, Corinne David-Ferdon, and Caroline
Evans review research on acculturation and violence among ethnic minority adolescents
in the United States. Results of their review suggest that, for Hispanic and Asian
adolescents, assimilation to US culture represented a risk for violence victimization and
perpetration, and that family relationship processes may mediate these associations.
Smokowski et al. propose future research directions and implications for intervention.
In chapter 19, Ana Abraído-Lanza, Karen Flórez, and Rachel Shelton review research on
acculturation and physical activity among US Hispanics. Contrary to the immigrant
paradox, Abraído-Lanza et al. conclude that Hispanics who are more oriented toward US
culture are more likely to be physically active during their leisure time. Nonetheless,
these authors note that much more work remains to be done to investigate the links
between acculturation and physical activity—including using objective measures of
physical activity and using more sophisticated measures of acculturation (i.e., the
majority of extant research uses unidimensional measures or markers). The chapter
concludes with recommendations for expanding and strengthening this literature.
In chapter 20, Aimee Afable and Eliseo Pérez-Stable provide a review of literature on
acculturation and chronic disease (primarily obesity, metabolic syndrome, and diabetes).
Afable and Pérez-Stable adopt a community-focused perspective, where the areas in
which migrants settle (e.g., walkable urban areas versus car-oriented suburbs) affect the
extent of relationship between acculturative processes and chronic disease symptoms.
These authors also consider the role of country-of-origin factors, such as increasing
obesity and diabetes rates in sending countries such as Mexico, China, and India, in
Page 18 of 26

determining how acculturation might affect chronic disease outcomes in migrants to the
United States. Afable and Pérez-Stable suggest ways in which the interactions among
country-of-origin health profiles, setting of settlement, and acculturation might contribute
to chronic disease risk.
Section 3: The Role of Culture and

Acculturation in Intervention Design and
Adaptation
In chapter 21, Leopoldo Cabassa presents a fotonovela intervention for depression and
other mental health problems. The fotonovela—a video documentary—was designed so as
to be culturally responsive to the Hispanic cultural proscription against seeking mental
health services. Cabassa describes how the fotonovela can increase Hispanic adults’
mental health literacy and understanding of available mental health services. He reviews
research testing the efficacy of the fotonovela intervention in increasing knowledge about
depression treatments and in reducing stigma regarding seeking help.
In chapter 22, Sara St. George and her colleagues describe the development of culturally
targeted preventive interventions for health behaviors and conditions such as substance
use, sexual risk taking, obesity, and diabetes. These authors describe a number of
intervention programs that have been developed or adapted according to the cultural
values, beliefs, and mores of the target population. They describe ways in which such
adaptations can be undertaken and provide a case example using a family-based
preventive intervention that was developed for use with US Hispanics and has been
adapted for use in other countries.
In chapter 23, Felipe Castro, Tara Perkins, and Maria Isabel Hombrados Mendieta
address the challenge and tension between administering an intervention to a new
cultural group versus adapting it for use with that group. Castro et al. discuss how
acculturation and cultural processes affect the intervention needs of individuals and
populations, and they review the effects of specific community contexts in moderating
ways in which acculturation informs intervention adaptation. For example, border
contexts differ considerably from other types of contexts in terms of cultural exposures
and profiles. Castro et al. also describe various types of cultural adaptations and their
roles within the evolution of prevention science.
In chapter 24, Martica Bacallao and Paul Smokowski describe the design and evaluation
of an intervention to promote bicultural adaptation in US Hispanic migrant parents and
Page 19 of 26

their adolescent children. Bacallao and Smokowski review the etiological research that
guided the development of the intervention and provide detailed descriptions of the
sessions. Research assessing the promise of the intervention is also reviewed.
Summary and Conclusion

This introductory chapter has briefly reviewed what we know about acculturation and has
juxtaposed three primary streams of acculturation-related work—basic theorizing and
research on acculturative processes, applied (largely epidemiological) research linking
acculturation with health behaviors and outcomes, and intervention principles and
programs drawing on acculturation-related principles to prevent or treat problematic
health outcomes. These strands of literature have intersected only superficially, and our
primary goal for this book is to place them alongside one another so that cross-pollination
can occur. In the closing chapter, we outline additional steps that we recommend for the
field of acculturation and health, based on the material presented in the chapters.
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Seth J. Schwartz
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Jennifer Unger
Keck School of Medicine, University of Southern California
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Acculturation and Health: State of the Field and Recommended Directions

Chapter · February 2017

Seth J Schwartz Jennifer B Unger

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Subject: Psychology, Health Psychology Online Publication Date: Jan 2017

Abstract and Keywords

Keywords: acculturation, health, measurement, immigrant, research, outcome

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Specifying and Operationalizing Meanings of

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Acculturation as an Intergroup Process

A primary social-psychological contribution to the study of acculturation is the framing of

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example, Canada is generally considered to be highly multicultural, in that migrants are

Social-psychological research indicates that migrants are likely to be viewed unfavorably

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Acculturation and Health Outcomes

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Indeed, a major challenge in clinical and epidemiological studies, which constitute a

Unintended Consequences of Measuring Acculturation Using

First, we believe it is important to discuss some of the “unintended consequences” of

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Potential Solutions to the Measurement of Acculturation in Health-

Clearly, the complexity of acculturation—involving multiple cultural streams, multiple

First, it is critical to at least measure receiving-culture acquisition and heritage-culture

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are an additional step removed from construct-valid indices of acculturation—to index

Because acculturation represents an interplay between migrants and their social-cultural

Given that acculturation is, by definition, a longitudinal phenomenon, where possible

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Description of and Goals for the Present

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Section 1: Basic Acculturation Theory and

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In chapter 8, Richard Cervantes and Thuy Bui adopt a life-domain perspective on

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Section 2: Associations Between Acculturation

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Section 3: The Role of Culture and

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Summary and Conclusion

Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology, 46,

Berry, J. W. (2006). Mutual attitudes among immigrants and ethnocultural groups in

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Bleich, E. (2009). Where do Muslims stand on ethno-racial hierarchies in Britain and

Brubaker, R. (2001). The return of assimilation? Changing perspectives on immigration

Brüβ, J. (2008). Experiences of discrimination reported by Turkish, Moroccan, and

Deaux, K. (2006). To be an immigrant. New York, NY: Russell Sage Foundation.

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Ferguson, G. M., & Bornstein, M. H. (2013). Tridimensional (3D) acculturation: Culture

Golash-Boza, T. M. (2012). Immigration nation: Raids, detentions, and deportations in

Henderson, T. J. (2011). Beyond borders: A history of Mexican migration to the United