Elsevier

Social Science & Medicine

Volume 72, Issue 2, January 2011, Pages 256-264
Social Science & Medicine

“So We Adapt Step by Step”: Acculturation experiences affecting diabetes management and perceived health for Chinese American immigrants

https://doi.org/10.1016/j.socscimed.2010.11.010Get rights and content

Abstract

This study examines how acculturation affects type 2 diabetes management and perceived health for Chinese American immigrants in the U.S. Acculturation experiences or cultural adaptation experiences affecting diabetes management and health were solicited from an informant group of immigrant patients and their spouses (N = 40) during group, couple and individual interviews conducted from 2005 to 2008. A separate respondent group of immigrant patients and their spouses (N = 19) meeting inclusion criteria reviewed and confirmed themes generated by the informant group. Using interpretive phenomenology, three key themes in patients’ and spouses’ acculturation experiences were identified: a) utilizing health care, b) maintaining family relations and roles, and c) establishing community ties and groundedness in the U.S. Acculturation experiences reflecting these themes were broad in scope and not fully captured by current self-report and proxy acculturation measures. In the current study, shifting family roles and evaluations of diabetes care and physical environment in the U.S. significantly affected diabetes management and health, yet are overlooked in acculturation and health investigations. Furthermore, the salience and impact of specific acculturation experiences respective to diabetes management and perceived health varied across participants due to individual, family, developmental, and environmental factors. In regards to salience, maintaining filial and interdependent family relations in the U.S. was of particular concern for older participants and coping with inadequate health insurance in the U.S. was especially distressing for self-described lower-middle to middle-class participants. In terms of impact, family separation and relocating to ethnically similar neighborhoods in the U.S. differentially affected diabetes management and health due to participants’ varied family relations and pre-migration family support levels and diverse cultural and linguistic backgrounds, respectively. Implications for expanding current conceptualizations and measures of acculturation to better comprehend its dynamic and multidimensional properties and complex effects on health are discussed. Additionally, implications for developing culturally-appropriate diabetes management recommendations for Chinese immigrants and their families are outlined.

Research highlights

► This study identifies acculturation stressors and buffers overlooked in research. ► Health care use, family relations and community ties affected diabetes management. ► Qualitative methods provide a holistic understanding of acculturation and health.

Introduction

Although prevalence rates of type 2 diabetes among Chinese Americans are two times higher than for the general population (McNeely & Boyko, 2004), research on diabetes management issues for this ethnic group is surprisingly limited. The few studies on this topic found that Chinese American immigrants encounter distinct cultural and family issues that potentially complicate their diabetes management and overall health (Chesla and Chun, 2005, Chesla et al., 2009, Chun and Chesla, 2004, Fisher et al., 2004, Jayne and Rankin, 2001). Acculturation issues in managing this disease however have not been thoroughly explored for this ethnic group. Although definitions of acculturation vary across studies, fundamentally it is a process of adjustment and adaptation to a new culture involving varying instances of cultural learning, maintenance, and synthesis (Chun and Akutsu, 2009, Marin et al., 2003). Given that over 70% of Chinese Americans are first-generation immigrants (Shinagawa & Kim, 2008), acculturation effects on diabetes management is a pertinent issue for exploration.

To date, only one study (Fisher et al., 2004) directly examined the relationship of acculturation to diabetes management for Chinese American immigrants. Using the Suinn-Lew Asian Self Identity Acculturation Scale (Suinn, Ahuna, & Khoo, 1992), results showed that highly-acculturated immigrants reported less negative effects of diabetes on their quality of life and better general health than their less-acculturated peers. However, specific acculturation experiences underlying these observed relationships were not explored.

Other studies have identified compelling linkages between acculturation and other diabetes-related outcomes for Asian Americans. For instance, investigations using proxy acculturation measures (e.g., years of U.S. residency, generational status, birthplace) have reported elevated type 2 diabetes risk with increased acculturation (Hosler and Melnik, 2003, Huang et al., 1996). Implicated in this relationship are higher obesity rates (Candib, 2007, Gomez et al., 2004) and related lifestyle changes (i.e., higher caloric intake, adoption of unhealthy U.S. diet and food preferences, less physical activity) presumably resulting from increased exposure to American culture (Abate and Chandalia, 2003, Lu and Cason, 2004, Unger et al., 2004). Studies using proxy acculturation measures also show that acculturation affects health care experiences relevant to diabetes management. Specifically, less acculturated Asian Americans underutilize health care (Salant & Lauderdale, 2003) and report more communication difficulties with health care providers than their more acculturated peers (Green et al., 2005, Ngo-Metzger et al., 2003).

Still, findings on acculturation and these diabetes-related outcomes for Chinese immigrants are sometimes mixed and difficult to interpret. For instance, in regard to type 2 diabetes risk, a study of Chinese Americans did not find a significant relationship between acculturation scale scores and disease rates (Kandula et al., 2008). Also, length of North American residency was unrelated to body weight for Chinese immigrants (McDonald & Kennedy, 2005). In terms of health behaviors, Chinese women with extended North American residency consumed more fruits and vegetables, but were also more likely to adopt a high-fat Western diet than their more recently immigrated peers (Satia et al., 2001). Regarding health care experiences, duration of U.S. residency was unrelated to health care utilization for a Chinese American immigrant sample (Miltiades & Wu, 2008).

In sum, the relationship between acculturation and diabetes management among Chinese immigrants is not fully understood due to a lack of studies on this topic and mixed findings on acculturation and diabetes-related outcomes. Mixed findings largely stem from an overreliance on proxy and self-report acculturation measures that do not fully capture this construct’s multidimensional and dynamic properties and complex relationship to health (Chun et al., 2007, Myers and Rodriguez, 2003, Perez-Escamilla and Putnik, 2007, Salant and Lauderdale, 2003). Acculturation is multidimensional because it encompasses multiple domains of behavioral, cognitive and emotional adaptive functioning (Chun, Balls Organista, & Marin, 2003). Acculturation is a dynamic process because demands or pressures to adapt, such as pressures to speak English or endorse new cultural norms, can fluctuate across different social and cultural contexts or situations (Trimble, 2003). Different individual and family goals and motives for cultural adaptation add to the dynamic qualities of acculturation (Chun & Akutsu, 2009). Multiple acculturation experiences, including variable levels of “acculturative stress” or stress from cultural adaptation demands (Chun, Balls Organista, & Marin, 2003), can thus emerge for different immigrants, plausibly affecting their diabetes management and health in complex ways. In this context, proxy acculturation measures are imprecise because they do not directly assess the nature of individual cultural adaptation experiences (Chun, Balls Organista, & Marin, 2003). Self-report measures can also be problematic because the acculturation domains assessed may be insufficient and their salience or importance to individuals’ acculturation experiences may vary (Chun, 2006). In this latter regard, composite scale scores may obscure differential effects of acculturation domains on specified outcomes (Abe-Kim et al., 2001, Ying, 1993), including for diabetes management and health outcomes (Salant & Lauderdale, 2003). Lastly, both proxy and self-report acculturation measures do not directly evaluate the context in which acculturation unfolds, thus important family, cultural and sociopolitical contexts shaping cultural adaptation and health are overlooked. Consequently, fundamental questions concerning the nature of acculturation and its relationship to diabetes management and health – namely, how do Chinese immigrants actually experience acculturation, and how do these experiences complicate or support their diabetes management and health? – largely remain a matter of conjecture.

A primary goal of this study was to articulate the complex ways in which acculturation affects diabetes management and perceived health for first-generation Chinese immigrants in the U.S. Special attention was given in identifying key acculturation experiences, including instances of stressful or successful cultural adaptation, which respectively complicated or facilitated their diabetes management. Qualitative research methods were utilized to comprehend the multidimensional and dynamic properties of acculturation based on immigrant participants’ extended narratives of their cultural adaptation experiences. Qualitative methods also allowed for findings and interpretations that were culturally-anchored in immigrant participants’ daily diabetes management and health practices.

Section snippets

Method

This interpretive comparative interview study was conducted from 2005 to 2008 with an informant group of 20 foreign-born Chinese American couples in which at least one member was diagnosed with type 2 diabetes. All informants spoke Cantonese, resided in the U.S for an average of 14.7 years (SD = 13.6) and came from mainland China (55%) or Hong Kong (45%). On average, they were 62-years old (SD = 9.2), reported 11.7 years of formal education (SD = 5.3), and had been married for 34 years

Results

Acculturation experiences affecting type 2 diabetes management and perceived health were identified from the narratives of Chinese immigrant patients (P) and spouses (S) in the current study. These acculturation experiences centered on three key themes: a) utilizing health care, b) maintaining family relations and roles, and c) establishing community ties and groundedness in the U.S. Participants reported variable acculturative stress levels across these themes that differentially affected

Acknowledgements

This work was supported by the National Institute of Nursing Research Grant R01-NR009111 (Principal Investigator: Catherine A. Chesla). We thank the following organizations and individuals: the California Pacific Medical Center; the Chinese Community Health Resource Center; Donaldina Cameron House; North East Medical Services; University of California San Francisco (UCSF) Diabetes Teaching Center; UCSF Lakeshore Family Practice; Peggy Huang; Kenneth Chang; Y.H. Cheng; Eunice Lew; Phiona Tan;

References (36)

  • C.A. Chesla et al.

    Cultural and family challenges to managing type 2 diabetes in immigrant Chinese Americans

    Diabetes Care

    (2009)
  • K.M. Chun

    Conceptual and measurement issues in family acculturation research

  • K.M. Chun et al.

    Assessing Asian American family acculturation in clinical settings: guidelines and recommendations for mental health professionals

  • K.M. Chun et al.

    Cultural issues in disease management for Chinese Americans with type 2 diabetes

    Psychology and Health

    (2004)
  • K.M. Chun et al.

    Conducting research with diverse Asian American groups

  • M.Z. Cohen et al.

    Hermeneutic phenomenological research: A practical guide for nurse practitioners

    (2000)
  • L. Fisher et al.

    Patient-appraised couple emotion management and disease management among Chinese American patients with type 2 diabetes

    Journal of Family Psychology

    (2004)
  • Cited by (75)

    • Chinese, Korean, and Japanese immigration to the US: Migration patterns and psychological adjustment

      2023, Psychosocial Experiences and Adjustment of Migrants: Coming to the USA
    • A qualitative study exploring diabetes resilience among adults with regulated type 2 diabetes mellitus

      2020, Diabetes and Metabolic Syndrome: Clinical Research and Reviews
      Citation Excerpt :

      The resilient condition of the participants is characterized by the ability to be adaptive to their condition, to be patient when undergoing self-care and to always engage in positive thinking. Adaptability when undergoing the conditions associated with DM requires a step-by-step process [28]. During the process of adapting to diabetes mellitus, the sufferers have a dynamic nature while making major changes to their cognitive, emotional, and behavioral structures to achieve a better condition and life [29].

    View all citing articles on Scopus
    View full text