6 reserch

AlcoholLocation1.pdf

Risk and Protective Factors of Alcohol Use Disorders among Filipino Americans: Location of Residence Matters

Wooksoo Kim, Ph.D., M.S.W. School of Social Work, University at Buffalo, The State University of New York, Buffalo, New York, USA

Isok Kim, L.C.S.W. M.S.W., M.A. School of Social Work, University of Michigan, Ann Arbor, Michigan, USA

Tom H. Nochajski, Ph.D. School of Social Work, University at Buffalo, The State University of New York, Buffalo, New York, USA

Background: Despite the growing number of Asian Americans (AA) in the United States, research on alcohol abuse in this popula- tion is sparse. Although AA have few alcohol use disorders (AUD) as an aggregate group, within-group variations in AUD need to be explored among specific ethnic groups in this population. Ob- jectives: This study compared correlates of 12-month prevalence of AUD between Filipino Americans who currently drink alcohol and live in San Francisco (SF) or Honolulu. Methods: Data from the 1998–1999 Filipino American Community Epidemiological Survey (N = 537) were used to test two hypotheses: 1) current drinkers in SF and Honolulu will differ in the characteristics and prevalence of AUD and 2) current drinkers in SF and Honolulu do not share the same protective and risk factors of AUD. Results: Current drinkers from the two regions substantially differed in age, years of educa- tion, age at first drink, religiosity, ethnic identity, psychological dis- tress, the nativity status, as well as the prevalence of AUD. Logistic regression models revealed that AUD risk factors were different for SF current drinkers (higher psychological distress, U.S.-born, and lower religiosity) compared to Honolulu drinkers (more years of education and lower emotional support). Conclusion: Filipino American drinkers living in SF and Honolulu have different risk and protective factors for AUD. Health professionals need to be aware of this difference when screening for factors associated with AUD among Filipino Americans. Scientific Significance: The cur- rent study revealed the importance of socioenvironmental context (location of residence) in predicting AUD among an Asian ethnic group.

Keywords Acculturation, alcohol use disorder, Asian Americans, emotional support, Filipino Americans, mental health, so- ciocultural contexts

Address correspondence to Isok Kim, School of Social Work, University of Michigan, Ann Arbor, Michigan, USA. E-mail: kimisok@umich.edu

INTRODUCTION Asian Americans (AA) are the fastest growing and most di-

verse segment of the U.S. population (1), yet they are not well represented in studies examining alcohol abuse and dependence (2–4). In national surveys, AA are shown to have consistently lower rates of alcohol use disorders (AUD) (i.e., alcohol abuse and dependence) compared with other ethnic groups (5). How- ever, recent studies also point to the increasing trend of preva- lence and risk for AUD among AA (6).

More importantly, there are substantial variations in the pat- terns of alcohol consumption, AUD, and the associated risk fac- tors among AA (2). Alcohol use among Asians has been found to be related to specific ethnic group membership (7, 8), and nativity and gender (9). Thus, studies that aggregate Asian eth- nic groups may gloss over significant within-group differences and may perpetuate the myth of model minority (10). There- fore, it is important for researchers to pay special attention to variations within the AA population when considering alcohol consumption and AUD.

Current research findings on the general population indicate a number of risk factors associated with AUD: having the first al- coholic drink at a young age (11, 12), lower educational achieve- ment (13–15), lower religious participation (16, 17), and higher psychological stress (18–21). However, AUD risk and protec- tive factors may not be consistent across AA ethnic groups for the following reasons. First, acculturation is considered an im- portant moderating factor on certain mental health outcomes, including AUD, for Asian ethnic groups. For example, Hender- shot and colleagues (22, 23) found that while acculturation was a risk factor for young Korean adults’ drinking behavior, it was a negligible factor among their Chinese counterparts. Second Na- tivity (being U.S.-born) may also be an important factor since studies have shown that U.S.-born AA are at greater risk for de- veloping AUD (24). Among young college students, Chinese,

214

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 215

Filipino, Korean, and Vietnamese female undergraduates who were born in the United States were at higher risk for increased alcohol use compared to foreign-born females (9).

FILIPINO AMERICANS IN SAN FRANCISCO AND HONOLULU

After the Immigration and Nationality Act of 1965 lifted national-origin quotas, a large number of Asians immigrated to the United States. In many cases, Filipino American immigrants face an arduous task acculturating to U.S. society. However, acculturative stress may depend on the specific interaction be- tween an individual and his/her sociocultural environment. The different reasons for immigrating to the United States may en- gender different sociocultural environments with respect to the level of family and community support, with the latter serving as a buffer for negative outcomes (26). Filipinos immigrating to Hawaii (Honolulu) did so to join their families, whereas those who migrated to California (San Francisco [SF]) did so to find employment (25). In addition, Asian and Pacific Islanders (API) comprise a majority of the Honolulu County population (52.1%), whereas the proportion of API is only 31.8% in SF County (33). Due to the differences in the sociocultural envi- ronments resulting from the reasons for immigrating, the same ethnic group may experience differential adaptive and accultura- tive stress. This may in turn result in differential health behavior outcomes, such as AUD.

In this study, we compared the risk and protective factors of AUD for Filipino American drinkers by location of residence (SF versus Honolulu). We hypothesized the following: 1) Fil- ipino American current drinkers in SF and Honolulu will differ in the characteristics and the prevalence of AUD and 2) protec- tive and risk factors for AUD will differ for Filipino American current drinkers in SF and Honolulu.

METHODS

Sample We analyzed data from the 1998–1999 Filipino American

Community Epidemiological Study (FACES). Data and a de- tailed description of the sampling procedure can be found else- where (27, 28). Using a stratified probabilistic sampling tech- nique, only one eligible person was randomly selected for an interview from each targeted household in Honolulu and SF. Re- spondents were required to be of Filipino descent and between the ages of 18 and 65 years. On average, 90-minute interviews were conducted using the language that the respondents pre- ferred, including English, Tagalog, or Illocano. A total of 2,285 interviews were completed from solicited households, which reflected a response rate of 78%. Of the 2,285 total respondents in the FACES study, our study used 537, who were identified as current drinkers who consumed alcohol at least once in the past 12 months.

Measures Alcohol Use Disorders (AUD)

Respondents who met the criteria for alcohol abuse or de- pendence in the past 12-months according to Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM- IV) (29) were positively identified as cases with AUD (1 = AUD, 0 = normal drinkers).

Age at First Drink Age at first drink was measured based on respondents’ self-

reported age when they first drank alcohol intentionally.

Psychological Distress Psychological stress was measured using a 20-item subscale

from the Symptom Checklist-90-Revised (SCL-90-R) (30), item choices ranged from not at all (1) to extremely (5). The Cron- bach’s alpha was .92 for the study sample.

Ethnic identity Ethnic identity was measured by a 9-item scale derived from

the Multiethnic Identity Measure (MEIM) (31). A 4-point rating scale, ranging from Strongly agree (1) to Strongly disagree (4), was used to assess respondents’ level of ethnic identify. The Cronbach’s alpha for this scale was .74 for the sample.

Acculturation Nativity, years in the United States, age at immigration, and

English language proficiency were considered as proxies for acculturation. After preliminary analyses indicated that includ- ing all of these variables caused multicollinearity problems and that the variable nativity was able to explain the largest vari- ance in the regression model, Nativity was selected to report the acculturation status (U.S.-born = 1, immigrants = 0).

Religiosity Religiosity was measured using 3 items and reflected the fre-

quency of attendance at various religious and spiritual activities or events, using a 5-point scale ranging from never (1) to once a week or more (5), with the higher number indicating high levels of religiosity. The Cronbach’s alpha for this scale was .72 for the sample.

Emotional Support Twenty items asked about the degrees to which the respon-

dents perceived emotional support from their spouse/partner, relatives, and friends. The responses ranged from none at all (1) to a lot (4). The Cronbach’s alpha for this scale was .91 for the sample.

Years of Education The number of years of education was used as a proxy for

socioeconomic status (SES). Initially, monthly income, employ- ment status, and years of education were considered. Due to

216 W. KIM ET AL.

potential multicollinearity issues, the years of education, which explained the largest variance, was included as the proxy for SES in the model.

Demographic Variables Demographic variables included age, gender (male = 1, fe-

male = 0), and marital status (married/cohabiting = 1, single, divorced, separated, or widowed = 0).

Analyses STATA 10.1 svy (32) commands were used to take into

account the sample design effects so that we could estimate standard errors in the presence of stratification of probability sampling. We used the bivariate analyses and examined the Variance Inflation Factor (VIF) scores to rule out violations of multicollinearity. In the descriptive analyses, variables were compared between the SF and Honolulu samples using t-test statistics for continuous variables or chi-square test for cate- gorical variables. A series of logistic regression analyses were conducted to identify protective and risk factors for SF and Honolulu sample. First, hierarchical logistic regression analy- ses testing the interaction effects were performed to determine if the stratified analyses by region was warranted. Then a stratified logistic regression model by location of residence (SF versus Honolulu) was used to test the study’s hypotheses.

RESULTS

Descriptives Table 1 presents weighted descriptive statistics on the vari-

ables included for overall current drinkers and by San Francisco and Honolulu groups. The overall sample had a majority of males (74.5%) with an average age of 38.7 years (range: 18 to 65 years), and about 56% of the sample was married/cohabiting. The mean age at first drink was 16.7 years, with an AUD rate of 9.2%.

Gender composition, marital status, and emotional support were not significantly different between the two subgroups. However, relative to the individuals in the Honolulu group, in- dividuals in the SF group were significantly younger and more educated. They also reported higher levels of psychological dis- tress and religious participation, lower levels of ethnic identity, and were less likely to be native born. Additionally, they had a higher prevalence of AUD and initiated their first drink at a younger age than the Honolulu group. When analyzed by nativ- ity and location of residence, Filipino immigrants in Honolulu had the lowest AUD rate (2.8%), followed by U.S.-born Filipino Americans in Honolulu (7.9%) and Filipino immigrants in SF (9.3%). U.S.-born Filipino Americans in SF had the highest (24.4%)—a more than 8-fold difference in the prevalence rate, compared to Filipino immigrants in Honolulu.

TABLE 1. Selected descriptive statistics among Filipino American current drinkers: 1998–1999, Filipino American Community

Epidemiological Study (FACES).

San Francisco (n = 317) Honolulu (n = 220) All Current Drinkers

(N = 537) Location of Residence 58.0% (.02) 42.0% (.02) 100% Age† 37.4 (.75) 40.4 (.85) 38.7 (.57) Gender

Male 74.0% (.03) 75.2% (.03) 74.5% (.02) Female 26.0% (.03) 24.8% (.03) 25.5% (.02)

Marital Status Married/Cohabit 53.9% (.03) 59.1% (.04) 56.0% (.02) S/D/S/W 46.1% (.03) 40.9% (.04) 44.0% (.02)

Years of education‡ 14.5 (.12) 11.1 (.34) 13.1 (.18) Age at first drink∗ 16.4 (.25) 17.2 (.30) 16.7 (.19) Religiosity‡ 2.90 (.07) 2.52 (.07) 2.74 (.05) Ethnic identity‡ 3.39 (.03) 3.59 (.03) 3.47 (.02) Psychological distress† 1.45 (.03) 1.32 (.04) 1.40 (.02) Emotional support 3.41 (.04) 3.48 (.05) 3.44 (.03) Nativity‡

U.S. born 28.0% (.03) 45.4% (.04) 35.3% (.02) Immigrant 72.0% (.03) 54.6% (.04) 64.7% (.02)

Alcohol use disorder (AUD)† 12.3% (.02) 5.0% (.02) 10.0% (.01)

Note: The analytic sample for the current study includes FACES respondents who drank alcohol in the past 12 months and who provided complete data for all covariates. S/D/S/W = single, divorced, separated, or widowed. Standard errors are reported in parentheses.

∗p <.05; †p <.01; ‡p <.001. Bold-faced numbers indicate statistically significant differences in SF, compared to Honolulu sample.

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 217

TABLE 2. The results of the logit regression model with interaction terms regressed on AUD among Filipino American current drinkers

by San Francisco and Honolulu: 1998–1999 FACES (N = 537). Interaction between location of residence (San Francisco = 1)

and other independent variables

Interaction terms with Control Variables: Age −.01 (.03) Gender (male = 1) .57 (1.28) Marital status (married = 1) .14 (.98)

Interaction terms with Main Variables: Years of education −.24 (.14)ˆ Age at first drink −.27 (.10)∗ Religiosity .14 (.83) Ethnic identity −.22 (.84) Psychological distress .80 (.64) Emotional support 1.28 (.54)∗

Nativity (U.S.-born = 1) .18 (.69) Constant (b) −3.49 (1.16) Note: Only the interaction terms are reported with beta coefficients

for the purpose of providing statistical rationale for warranting subse- quent stratified logistic regression analyses by location of residence. All continuous variables are grand-mean centered to eliminate poten- tial multicollinearity problem with interaction terms. Standard beta co- efficients are reported with standard errors in parenthesis. Bold-faced numbers indicate significant results (at ˆp < .10; ∗p < .05).

To test whether the stratified analyses by region (SF ver- sus Honolulu) were warranted, we used the logit regression analyses with interactions between location of residence and other variables that included age, gender, marital status, years of education, age at first drink, psychological distress, nativity, religiosity, ethnic identity, and emotional support. The results appear in Table 2 and indicate that there were significant inter- actions between region and years of education (b = −.24; SE = .14); region and age at first drink (b = −.27; SE = .10); and region and emotional support (b = 1.28; SE = .54).

Table 3 shows the results of the two logistic regression analy- ses predicting AUD. Results from two logistic regression models stratified by region revealed different patterns in the regression model. For the SF group, psychological distress (odds ratios [OR] = 4.38; 95% confidence interval [CI] = 2.07, 9.24) and nativity (OR = 2.94; CI = 1.24, 6.97) were positively associated with having AUD. Marital status (OR = .35; CI = .13, .98), age at first drink (OR = .84; CI = .75, .94), and religiosity (OR = .62; CI = .42, .92) were negatively associated with having AUD. In contrast, among the Honolulu group, years of education (OR = 1.25; CI = 1.04, 1.50) were positively associated with having AUD, while emotional support (OR = .40; CI = .22, .73) was negatively associated with having AUD.

DISCUSSION This study demonstrated a newer understanding of risk and

protective factors for AUD among Filipino American current drinkers in SF and Honolulu. Past alcohol researchers have pointed out the importance of within-group variation among AA (2, 4), and recent findings have highlighted the heterogene- ity among Asian ethnic groups regarding AUD risks (7, 22). The present findings add to the growing body of knowledge con- cerning the complexity of factors associated with AUD among Filipino Americans.

Results from stratified analyses showed that the SF group consisted of higher proportion of immigrants, who reported more years of education, more religious participation, and greater ethnic identity than the Honolulu group. Previous studies have indicated that these factors have a tendency to lower risk for AUD (24). However, the SF group (12.3%) had more than twice the prevalence rate of AUD than those living in Honolulu (5.0%). This outcome seems counterintuitive because the Hon- olulu group had a higher proportion of U.S.-born individuals, which is the group identified in the literature as having greater risk for developing AUD (24). One reason for this counterintu- itive finding may be related to the fact that API is the majority of the population in Honolulu, and this may have engendered a stronger sense of ethnic community, which has an influence on the drinking patterns among Filipino Americans.

Almost a quarter of U.S.-born Filipino American drinkers in SF (24.4%) had an AUD, while the prevalence rate of the Fil- ipino U.S.-born drinkers in Honolulu was 9.3%. In other words, U.S.-born drinkers living in SF were over 2.5 times more likely than those in Honolulu to be at risk for AUD. This trend was con- sistent with the immigrant groups. Filipino immigrant drinkers living in SF had a 2.5 times higher rate of AUD (7.9%) than their counterparts in Honolulu (2.8%). The difference between the Filipino U.S.-born drinkers in SF and the Filipino immi- grant drinkers in Honolulu was almost eightfold. If the data had been aggregated, not accounting for nativity and location of residence, the differences would have been missed, and con- clusions would have been inaccurate. Future research needs to further explore and explain the nature of important factors that contribute to differences in AUD among Filipino American drinkers.

Although we did not explore the specific question about causality, we can speculate based on region differ- ences. That is, Filipino Americans in Honolulu may have more socioenvironmentally-based protection against develop- ing AUD. This may be due to a longer immigration history and a higher proportion of Asian populations in the surround- ing community that may have generated a more effective social support system. As Gee and colleagues (26) have demonstrated, the visibility and availability of social supports from the ethnic community are shown to protect against negative mental health outcomes. Similarly, our results show that emotional support protects against having AUD among Filipino drinkers in Hon- olulu, but not those in SF.

218 W. KIM ET AL.

TABLE 3. The results of Logistic regression analyses regressed on AUD among Filipino American current drinkers by San Francisco and

Honolulu: 1998–99 FACES.

San Francisco (n = 317) Honolulu (n = 220) Age 1.01 (.97, 1.06) 1.02 (.97, 1.07) Gender (1 = male) 2.24 (.64, 7.73) 1.26 (.14, 11.28) Marital Status (1 = Married/ Cohabit) .35 (.13, .98)∗ .31 (.06, 1.56) Years of education .98 (.81, 1.19) 1.25 (1.04, 1.50)∗

Age at first drink .84 (.75, .94)† 1.10 (.93, 1.31) Religiosity .62 (.42, .92)∗ .54 (.11, 2.66) Ethnic identity .88 (.32, 2.43) 1.09 (.30, 4.03) Psychological distress 4.38 (2.07, 9.24)‡ 1.96 (.72, 5.34) Emotional support 1.45 (.60, 3.51) .40 (.22, .73)†

Nativity (1 = U.S.-born) 2.94 (1.24, 6.97)∗ 2.04 (.75, 5.59) Note: Odds ratios are reported with 95% confidence intervals in parenthesis. Bold-faced numbers indicate significant results (at ∗p < .05; †p < .01; ‡p < .001).

Importantly, findings from the logistic regression analyses in- dicated that risk and protective factors of AUD were not equiv- alent between Filipino drinkers in SF and those in Honolulu. The results of the SF group were consistent with the current literature (11–21). The following criteria were associated with developing AUD: a high level of psychological distress, being U.S.-born, having the first alcoholic drink at a younger age, and low religiosity. Contrary to past findings, greater education sig- nificantly increased the odds of having AUD among those in the Honolulu group. Results from the Gilman et al. study (13), how- ever, did find that years of education did not significantly predict alcohol dependence in its Asian sample. Generally, most studies suggest that the level of education is negatively associated with AUD in the general population (13, 15), or no association in an Asian sample (13). It is possible that for Filipino Americans in Honolulu, the years of education engenders different social expectations in terms of drinking alcohol and thus influences the development of AUD in a different manner. Future studies need to examine intervening factors responsible for the adverse effects of years of education among Filipinos in Honolulu.

Two nonsignificant variables in both SF and Honolulu groups are worth mentioning here. Contrary to previous findings, gen- der was not a significant risk factor for having AUD among drinkers in this population. In other words, female Filipino drinkers were as vulnerable to the consequences of AUD as male Filipino drinkers. In addition, the direction of association between ethnic identity and AUD differed for SF and Hon- olulu groups. This suggests that inconsistent findings regarding the impact of ethnic identity on AUD may be explained when researchers analyze region-specific factors. There might be un- derlying socioenvironmental differences that interact with eth- nic identity that need to be explored in future research among this population.

Several limitations of this study should be noted. First, the fact that it was cross-sectional data prevented us from claim-

ing causal relationships among variables of interests. Second, self-reported survey designs can often influence the way that respondents answer certain items, vis-à-vis social desirability and recall biases. Third, despite the value of this dataset, the data is rather dated (collected in 1999), so the results may not be generalizable to the current Filipino population in the United States. However, to our knowledge, this is the only data avail- able to date that contains extensive data about alcohol abuse and dependence in Filipino Americans, which made this study’s analyses possible. Fourth, cross-cultural comparisons with non- Filipino groups or Filipinos living in the Philippines would have furthered our understanding of the etiology of AUD in this pop- ulation, but this was not possible because the original data col- lection was limited to Filipino Americans living in SF and Hon- olulu. In addition, nativity was a proxy measure of acculturation, and may not fully reflect stresses associated with acculturative processes. Our study was not able to include potentially im- portant factors of AUD, such as availability of alcohol. Recent studies have also suggested that perceived racial discrimination may be one of the critical factors influencing ethnic minorities’ health and mental health (3, 26–28). These factors should be addressed in future studies to extricate the etiology among this population.

Despite these limitations, our study contributed to the cur- rent knowledgebase about AUD among Filipino Americans. We demonstrated that important, yet rarely studied, within-group variations, i.e., nativity and location of residence, were found to affect the odds of having AUD. Second, our findings pro- vide critical insight for clinicians working with the Filipino populations in these two regions. Nationally based statistics might provide misleading information when it is applied to Asian ethnic groups because there is much variation within Asian subgroups. This study demonstrated the importance of sociocultural contexts in explaining health consequences. In this regard, information related to health and mental health outcomes

ALCOHOL USE DISORDER AMONG FILIPINO AMERICANS 219

should be interpreted with caution considering sociocultural environments where minority groups or Asian ethnic groups are situated. Thus, findings from the present study may be most useful in clinical setting where region-specific information is more relevant, rather than national level epidemiological find- ings.

Declaration of Interest This study was partly supported by the Substance Abuse and

Mental Health Administration (SAMHSA) Minority Fellowship Program (T06 SM058565-01), awarded to the second author through the Council on Social Work Education. The authors have no conflicts of interest to disclose. The authors alone are responsible for the content and writing of the paper.

REFERENCES 1. U.S. Bureau of Census. We the People: Asians in the United States Census

2000 Special Reports. Washington, DC: U.S. Government printing Office, 2004.

2. Caetano R, Clark CL, Tam T. Alcohol consumption among racial/ethnic minorities: theory and research. Alcohol Health and Research World 1998; 22(4): 233–241.

3. Chae DH, Takeuchi DT, Barbeau EM, Bennett GG, Lindsey JC, Stoddard AM, Krieger N. Alcohol disorders among Asian Americans: Associations with unfair treatment, racial/ethnic discrimination, and ethnic identification (the National Latino and Asian Americans Study, 2002–2003). Journal of Epidemiology and Community Health 2008; 62:973–979.

4. Ja DY, Aoki B. Substance abuse treatment: Cultural barriers in the Asian- American community. Journal of Psychoactive Drugs 1993; 25(1):61–71.

5. Grant BF, Dawson DA, Stinson FS, Chou SP, Dufour MC, Pickering RP. The 12-month prevalence and trends in DSM-IV alcohol abuse and de- pendence: United States, 1991–1992 and 2001–2002. Drug and Alcohol Dependence 2004; 74(3):223–234.

6. Sakai JT, Ho PM, Shore JH, Risk NK, Price RK. Asians in the United States: Substance dependence and use of substance-dependence treatment. Journal of Substance Abuse Treatment 2005; 29(2):75–84.

7. Chi I, Lubben JE, Kitano HH. Differences in drinking behavior among three Asian-American groups. Journal of Studies on Alcohol 1989; 50(1):15–23.

8. Zane N, Sasao T. Research on drug abuse among Asian Pacific Americans. Drugs and Society 1992; 6(3):181–209.

9. Lum C, Corliss HL, Mays VM, Cochran SD, Lui CK. Differences in the drinking behaviors of Chinese, Filipino, Korean, and Vietnamese college students. Journal of studies on Alcohol and Drugs 2009; 70:568–574.

10. Wong FY, Halgin R. The ‘model minority:’ Bane or blessing for Asian Americans? Journal of Multicultural Counseling and Development 2006, 34(1):38–49.

11. Dawson DA, Goldstein RB, Chou SP, Ruan WJ, Grant BF. Age at first drink and the first incidence of adult-onset DSM-IV alcohol use disorders. Alcoholism 2008; 32(12):2149–2160.

12. Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 1997; 9:103–110.

13. Gillman SE, Breslau J, Conron KJ, Koenen KC, Subraman SV, Zaslavsky AM. Education and race-ethnicity differences in the lifetime risk of al- cohol dependence. Journal of Epidemiology Community Health 2008; 62(3):224–230.

14. Harford TC, Muthen BO. The dimensionality of alcohol abuse and de- pendence: A multivariate analysis of DSM-IV symptom items in the National Longitudinal Survey of Youth. Journal of Studies on Alcohol 2001; 62(2):150–157.

15. Harford TC, Yi HY, Hilton ME. Alcohol abuse and dependence in college and noncollege samples: A ten-year prospective follow-up in a national survey. Journal of Studies on Alcohol 2006; 67(6):803–809.

16. Haber JR, Jacob T. Alcoholism risk moderation by a socio-religious di- mension. Journal of Studies on Alcohol and Drugs 2007; 68(6):912– 922.

17. Kendler KS, Gardner CO, Prescott CA. Religion, psychopathology, and substance use and abuse: A multimeasure, genetic-epidemiologic study. American Journal of Psychiatry 1997; 154(3):322–329.

18. Brady KT, Sonne SC. The role of stress in alcohol use, alcoholism treatment, and relapse. Alcohol Research and Health 1999; 23(4):263–271.

19. Courbasson CMA, Endler NS, Kocovski NL. Coping and psychological distress for men with substance use disorders. Current Psychology 2002; 21(1):35–49.

20. D’Avanzo CE, Frye B, Froman R. Culture, stress and substance use in Cambodian refugee women. Journal of Studies on Alcohol 1994; 55(4): 420–26.

21. Gong F, Takeuchi DT, Agbayani-Siewert P, Tacata L. Acculturation, psy- chological distress, and alcohol use: Investigating the effects of ethnic identity and religiosity. In Acculturation: Advances in Theory, Measure- ment, and Applied Research. Chun KM, Organista PB, Marin G (Eds.). Washington, DC: American Psychological Association, 2003.

22. Hendershot CS, Dliworth TM, Neighbors C, George WH. Differential effects of acculturation on drinking behavior in Chinese- and Korean- American college students. Journal of Studies on Alcohol and Drugs 2008; 69(1):121–128.

23. Hendershot CS, MacPherson L, Myers MG, Carr LG, Wall TL. Psychoso- cial, cultural and genetic influences on alcohol use in Asian American youth. Journal of Studies on Alcohol 2005; 66(2):185–195.

24. Hahm HC, Lahiff M, Guterman NB. Acculturation and parental attach- ment in Asian-American adolescents’ alcohol use. J Adolesc Health 2003; 33(2):119–129.

25. Liu JM, Ong PM, Rosenstein C. Dual chain migration: Post-1965 Filipino immigration to the United States. International Migration Review 1991; 25(3):487–513.

26. Gee GC, Chen J, Spencer MS, See S, Kuester OA, Tran D, Takeuchi D. Social support as a buffer for perceived unfair treatment among Filipino Americans: Differences between San Francisco and Honolulu. American Journal of Public Health 2006; 96(4):677–684.

27. Gee GC, Delva J, Takeuchi DT. Relationships between self-reported unfair treatment and prescription medication use, illicit drug use, and alcohol dependence among Filipino Americans. American Journal of Public Health 2007; 96:933–940.

28. Mossakowski KN. Coping with perceived discrimination: Does ethnic iden- tity protect mental health? Journal of Health and Social Behavior 2003; 44(3):318–331.

29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington, DC: American Psychiatric Associ- ation, 1994.

30. Derogatis LR. SCL-90 Administration, Scoring and Procedures Manual- I for R (revised) Version and Other Instruments of the Psychopathology Rating Scale Series. Towson, MD: Clinical Psychometric Research, 1977.

31. Phinney JS. The Multigroup Ethnic Identity Measure: A new scale for use with diverse groups. Journal of Adolescent Research 1992; 7(2):156–176.

32. StataCorp. Stata Statistical Software: Release 10. College Station, TX: StataCorp LP, 2007.

33. U.S. Bureau of Census. State and County QuickFacts. 2008. Retrieved March 02, 2010 from: http://quickfacts.census.gov/qfd/index.html

content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's

express written permission. However, users may print, download, or email articles for individual use.