6 reserch

AlcoholUse.pdf

SOCIO-CULTURAL FACTORS RELATED TO ALCOHOL USE

AMONG ASIAN AMERICANS

A dissertation submitted in partial fulfillment of the degree of Doctor of Philosophy from New York University School of Social Work

So-Youn Park

September 2010

Examining Committee Members:

Dr. Jeane W. Anastas, Ph.D. (Advisor)

Dr. Tazuko Shibusawa, Ph.D.

Dr. Duy Nguyen, Ph.D.

UMI Number: 3423005

INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript

and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.

UMI 3423005

unauthorized copying under Title 17, United States Code.

ProQuest LLC 789 East Eisenhower Parkway

P.O. Box 1346 Ann Arbor, MI 48106-1346

This dissertation is dedicated to my mother, who has supported me financially, physically, and emotionally. She has always said that she would invest in the education of her children before retiring. She truly believes in the power of education, in the importance of women’s independence, and in the individual’s power to use knowledge gained to give back to society. I love you, mom.

ACKNOWLEDGEMENTS

My doctoral education has been, in every sense of the word, a journey, and one that I

would not have completed without the support of many people.

I am very grateful to my dissertation committee members, who endlessly supported, encouraged, and guided me through every step of this process.

Dr. Jeane W. Anastas my dissertation chair, allowed me the freedom to explore through trial and error, and established an intellectually inspiring environment that challenged me to think more deeply. She also encouraged me to stay connected with social work education.

Dr. Tazuko Shibusawa generously contributed time and her expertise in research on Asian Americans, taught me the importance of the connection between practice and research, and always comforted me with her wonderful smile. Dr. Duy Nguyen was enormously helpful with methodology and patiently answered all my questions, and encouraged me to advance new perspectives on research.

I cannot thank my friends enough. My cohorts at school: Jan Wolff Bensdorf, Maya

Dolyle, Camille Huggins, Alexis Kuerbis, Karyn Marsh, Jennifer Mills, and James Railey. I am very lucky to have such encouraging and supportive friends.

A special thanks to Alexis Kuerbis, Camille Huggins, Soonhee Roh, Yeddi Park, Jennifer Mills, Maya Dolyle, and Ian Ong. Alexis helped edit my paper and gave comments filled with knowledge and wisdom. Camille Huggins, my study partner, provided insightful reflections. Soonhee Roh was warm and generous with valuable feedback. Yeddi Park genuinely listened to my concerns, kept my spirits up, and shared her knowledge. Jennifer Mills was a big help who gave many valuable suggestions and feedback, especially with the CIP. Maya Dolyle brought energy and intelligence. Ian Ong was always willing to help and encouraged me to think critically.

I am also indebted to the doctoral program at NYU’s Silver School of Social Work. Dr.

Lynn Videka, our dean, supported my fellow doctoral students and me with warmth, intelligence, and concern. Dr. James Martin, the doctoral program director, also provided me with the necessary assistance and support. Tandayi Jones, Ph.D. program administrator, responded promptly to my questions and took the time to update me on school news whenever I visited her. Dr. Robert Yaffee, research professor, patiently answered my countless statistical questions and contributed to my understanding of statistics. The Doctoral Student Association (DSA) organized very informative and effective workshops and seminars.

Many thanks to my Korean mentors and colleagues. Dr. Kunsook Bernstein and Dr. Jin

Y. Shin, my mentors, believed in me and accommodated my requests in every possible way. Haein Son, my long-time colleague, kept me connected with the Korean-American community and shared resources generously. Dr. Jinah Shin, Dr. Eunjung Ko, and members of the Korean American Behavioral Health Association showed interest in my research and lent encouragement and support.

I would like to extend my sincere thanks to Data Studio Service at Bobst Library at NYU—Frank Lopresti, Himanshu Mistry, David McGarry--my supervisors who gave me an opportunity to work as a lab consultant. They afforded me not only some needed income, but also a friendly environment conducive to learning and using new technology and statistics. Many thanks to my co-student consultants, Kevin Kai Du, Yasmin Grewal, Mashfiqur Khan, Angus Mungal, and Melissa Reese. We had interesting discussions, and they helped me better understand statistics and statistical software. It was fun to work with them.

An infinite thanks to my family and friends: Dr. Shin-Eun Choi, my mother; Dr. Eyun

Park, my sister; and Dr. Hyung Jun Park, my brother. Thank you for your eternal confidence in me, your unconditional support, and your encouragement in pursuing my goals. Although he has passed away, my father, Dr. Jin-Young Park, has been an inspiration for to me, and I will always be grateful to him for providing me with his guidance and a good education.

I would like to express my appreciation to my parents-in-law, Dr. Jaechol Chung and Dr.

Chaok Lee, who inspired me in many ways, and my sister-in-law, Myung Chung, and her husband, Dr. Jinyoung Park, for their support. My best friends: Wonhae Koh, Jooeun Lee, and Hakyung Sung, who have been there for me and nourished my mind and body. They are my second family. I would also like to thank Cullen Thomas, my long-time English tutor, and Jie- Eune Choi, Seunghee Hong, Seunghyun Son, and Jimin Kim for their continuous support, friendship, and encouragement. Special thanks to my dearest friend, Jung Euen Choi, who sometimes knew me better than I knew myself. She brought good ideas out of me when I doubted myself. And thank God for giving me strength and guidance throughout my life.

Finally, I am extremely grateful to my wonderful husband, Sanghyun Chung, for his

understanding, patience, and sacrifice throughout the process. Every step of the way, he understood me, loved unconditionally, and unwaveringly believed in my ability to succeed. At each dissertation milestone, he brought home my favorite comfort food and movies to cheer me up.

Park, So-Youn. Socio-cultural factors related to alcohol use among Asian Americans. New York University, Ph.D., September 2010.

This study examines factors related to alcohol use—acculturation, acculturative stress,

religiosity, and social support—for three distinct Asian American subgroups: Chinese, Filipino,

and Vietnamese Americans. The alcohol-use model that guided the study was derived from an

acculturation and acculturative-stress model that integrated stress-buffering theories.

This study was a secondary analysis of data from the National Latino and Asian Americans

Study (NLAAS), which collected information from a nationally representative sample of Asian

Americans, 18 years of age or older, residing in the United States. Unweighted sample sizes for

Chinese, Filipino, and Vietnamese Americans were 600, 508, and 520, respectively. Separate

analyses were conducted for each subgroup; results showed different drinking patterns for each.

For Chinese Americans, higher English-language proficiency (OR=1.12) or being second

(OR=5.87) or third (OR=3.61) generation were significantly related to increased alcohol use.

Among Filipino Americans, higher English-language proficiency (OR=1.22) and unfair treatment

(OR=1.09) were positively related to alcohol use while perceived racial/ethnic discrimination

(OR=0.48) were negatively related to alcohol use. For Vietnamese-Americans, only English-

language proficiency (OR=1.14) was significantly associated with increased drinking. Social

support and religiosity had both a positive and a negative impact on alcohol use across the three

groups depending upon which acculturative stressor was examined. The findings underscore the

importance of considering the heterogeneity of Asian Americans when designing relevant

assessments and interventions related to alcohol use.

TABLE OF CONTENTS

CHAPTER I: Introduction and Problems .................................................................................. 1

Purpose of the Study ................................................................................................................... 1 Problem of Statement .................................................................................................................. 1 Significance of the Proposed Study for Social Work ................................................................. 5

CHAPTER II: Literature Review ............................................................................................... 7

Alcohol Consumption ................................................................................................................. 7 Health Conseqeunces .............................................................................................................. 7 Measurement of alcohol Significance of Alcohol Consumption ............................................ 9

Description of the Asian American Population ........................................................................ 10 Chinese .................................................................................................................................. 12

Filipinos ................................................................................................................................ 12 Vietnamese ............................................................................................................................ 13

Prevalence of Alcohol Use among Asian Americans ........................................................... 14 Relevant Contributory Factors to Alcohol Use ......................................................................... 19

Biological Factors ................................................................................................................. 19 Socio-cultural Factors ........................................................................................................... 20

Acculturation..................................................................................................................... 20 Models of acculturation ................................................................................................ 21 Measuring levels of acculturation and acculturative stress ........................................... 22 Acculturation scale approriate for Asian Americans .................................................... 24 Factors associated with acculturation ........................................................................... 25 Acculturation and Alcohol Use ......................................................................................... 26 Acculutration model for alcohol use ............................................................................. 26 Acculutration stress ....................................................................................................... 34

Acculturative stress model for alcohol use ................................................................... 35 Discrimination............................................................................................................... 37 Family cultural conflict ................................................................................................. 38

Stress-buffering hypotheis: The role of social support and religisoity ............................. 40 Social support................................................................................................................ 41 Religiosity ..................................................................................................................... 42

Summary ................................................................................................................................... 44 CHAPTER III: Method .............................................................................................................. 46

Statement of Research Questions and Explored Hypotheses ................................................... 46 Data Source and Sample ........................................................................................................... 51

Method of Sampling .......................................................................................................... 52

Study Procedure ........................................................................................................................ 52 Measures ................................................................................................................................... 53

Acculturation.................................................................................................................... 53 Acculturative stress .......................................................................................................... 54

Discrimination............................................................................................................. 54 Family cultural conflict ............................................................................................... 55 Social support .................................................................................................................. 55 Religiosity ........................................................................................................................ 55

Alcohol use ..................................................................................................................... 56 Demographic Variables ................................................................................................... 57

Analytic Plan ............................................................................................................................ 57 Ethical Issues ............................................................................................................................ 61

CHAPTER IV: Results ............................................................................................................... 63

Chateristics of the Sample ........................................................................................................ 63 Alcohol use .......................................................................................................................... 65

Addressing Multicollinearity .................................................................................................... 68 Factors Related to Alcohol Use among Chinese Americans .................................................... 69 Factors Related to Alcohol Use among Filipon Americans ...................................................... 77 Factors Related to Alcohol Use among Vietnamse Americans ................................................ 86 Summary of Findings for Chinese, Filipino, and Vietnamse Americans ................................. 93 CHAPTER V: Discussion ........................................................................................................... 94

Alcohol Use .............................................................................................................................. 94 Acculturation............................................................................................................................. 96 Acculturative Stress .................................................................................................................. 97 Filipino Americans .............................................................................................................. 98 Chinese and Vietnamese Americans ................................................................................. 100 The Relationship between Acculturation and Acculturativstress ........................................... 100 Social Support/Religiosity ...................................................................................................... 101

Chinese Americans ........................................................................................................... 102 Filipino Americans ............................................................................................................ 103 Vietnamese Americans ..................................................................................................... 104 Study Limitations .................................................................................................................... 104 Implications............................................................................................................................. 107

Social work practice .......................................................................................................... 107 Social work policy ............................................................................................................ 111 Rcommendatiosn for Future Study ........................................................................................ 113 Conclusion .............................................................................................................................. 115

References .................................................................................................................................. 117

Appendices ................................................................................................................................. 148

Appendix A Unfair treatment scale ........................................................................................ 148 Appendix B Perceived racial/ethnic discrimination scale ...................................................... 150 Appendix C Family conflict scale ........................................................................................... 151 Appendix D Statistical regression models in path analysis: Oridinal logistic and ordinary least squares (OLS) regression……………………………………………………….152 Appendix E IRB approval notice ............................................................................................ 153 Appendix F Charaterisitcs of Chinese, Filipino, and Vietnamse Americans in weighted sample size……………………………………………………………………………...154 Appendix G Correlation matrix among all variables among Chinese Americans .................. 156 Appendix H Correlation matrix among all variables among Filipon Americans ................... 158 Appendix I Correlation matrix among all variables among Vietnamese Americans ............. 160 Appendix J Direct as well as indirect paths from generation to alcohol use .......................... 162

LIST OF TABLES

Table 1: Summary of available studies on acculturation and alcohol use .................................... 28

Table 2: Weighted and unweighted sample subgroup ................................................................. 63

Table 3: Characteristics of Chinese, Filipino, and Vietnamse Americans ................................... 66

Table 4: Ordinal logistic regression results for alcohol use among Chinese Americans .............. 70

Table 5: OLS regression results for acculturative stressors among Chinese Americans ............. 75

Table 6: Ordinal logistic regression results for alcohol use among Filipino Americans .............. 78

Table 7: OLS regression results for acculturative stressors among Filipino Americans ............. 84

Table 8: Ordinal logistic regression results for alcohol use among Vietnamse Americans ......... 87

Table 9: OLS regression results for acculturative stressors among Vietnamse Americans ........ 91

Table 10: Summary of results from hypothesis testing for the three groups ............................... 93

LIST OF FIGURES Figure 1: Proposed conceptual model for Asian Americans’ alcohol use .................................... 45

Figure 2: Diagram of expected pathways among predictors of alcohol use for Asian Americans50

Figure 3: Final model for Chinese Americans .............................................................................. 76

Figure 4: Final model for Filipino Americans .............................................................................. 85

Figure 5: Final model for Vietnamese Americans ........................................................................ 92

Chapter I

Introduction and Problems

Purpose of the Study

The purpose of this current study is to explore the interrelationships among factors that

contribute to alcohol use among Asian American adults, with particular attention to the socio-

cultural variables of acculturation, acculturative stress (discrimination and family conflict),

religiosity, and social support. A path model is proposed and tested to explore and test the

interrelationships of these variables and their association with alcohol use for three distinct

cultural subgroups: Chinese, Filipinos, and Vietnamese Americans.

Problem Statement

Alcohol is the most commonly used substance in the United States across all ethnic and

racial groups (U.S. Department of Health and Human Services [USDHHS], 2001). Alcohol use

significantly impacts society as a whole and individuals of all ethnic groups. While moderate

drinking may mitigate risk for certain diseases, including cardiovascular disease and diabetes, the

overall negative consequences of alcohol consumption far outweigh its benefits (Dufour, 1999).

According to Healthy People 2010 (USDHHS, 2010a), alcohol use contributes to a wide range of

health and social problems, including lost occupational productivity, domestic violence,

homelessness, teenage pregnancy, fetal alcohol syndrome, automobile accidents, and HIV/AIDS.

In the United States, among causes of death related to lifestyle, excessive alcohol use ranks third

(Center for Disease Control and Prevention [CDC], 2006).

While many studies have examined patterns of alcohol use and abuse among African

Americans and Hispanics, few have focused specifically on Asian Americans. Although Asian

Americans are the fastest-growing ethnic minority and suffer the same adverse health and social

consequences of alcohol use as other ethnic groups (Fong & Tsuang, 2007), research on alcohol

use within this ethnic group is scant (Ja & Aoki, 1993; Lee, Law, & Eo, 2003; Subramanian &

Takeuchi, 1999; Wong et al., 2007). The limited published data available suggest that Asian

Americans as a whole may have lower levels of alcohol abuse and related problems than other

ethnic groups (Klatsky, Seigelaub, Landy, & Friedman, 1983; Price, Risk, Wong, & Klingle,

2002; Substance Abuse and Mental Health Service Administration [SAMHSA], 1998).

To date, most research has studied Asian Americans as a single homogenous group,

without examining variability across subgroups (Kinto, Lubben, & Chi, 1989; Kuramoto, 1997;

Varma & Siris, 1996); however, the population of Asian Americans is composed of more than 30

subgroups, which differ in terms of religion, language, and other cultural features. Hence,

existing studies may not capture important variations in alcohol use among subgroups within the

Asian American population (Ja & Aoki, 1993; Lee et al., 2003; Makimoto, 1998; Subramanian &

Takeuchi, 1999; Wong et al.. 2007; Zane & Huh-Kim, 1998). Consequently, little is known

about variability in alcohol use within the Asian American population or about socio-cultural

factors that may contribute to such variability (Subramanian & Takeuchi, 1999). For a more

accurate picture of alcohol use and its determinants among Asian Americans, variability among

subgroups needs to be investigated with attention to multiple social-cultural factors that may

contribute to this variability and/or to alcohol consumption by Asian Americans as a whole.

A review of relevant literature on alcohol use among Asian Americans reveals several

weaknesses in existing data. First, few studies have addressed or compared the differential

impacts of Asian Americans’ level of acculturation and the experience of acculturative stress.

The acculturation model posits that alcohol use reflects the norms and practices of the society

into which a person is being acculturated, and some studies have demonstrated that Asian

Americans who are more acculturated to the U.S. drink more (Liu & Iwamoto, 2007; Wong et al.,

2007; Yi & Daniel, 2001). At the same time, the acculturative stress model posits that alcohol

use is associated with the stresses accompanying the process of acculturation to the mainstream

society, such as discrimination or family conflict, and studies have suggested that many

immigrant and ethnic minority populations drink alcohol as a means of coping with acculturation

stresses (Bhattacharya, 2005; D’Avanzo, Frye, & Froman, 1994; McLaughin, Raymond,

Murakami, & Goebert, 1987). However, few empirical studies have incorporated an examination

of both level of acculturation and acculturative stress in the same study, and few have taken into

account the potentially important moderating factors of social support and religiosity.

Second, most studies have focused on adolescents and college students, with few

assessing alcohol consumption and its predictors within adult populations. The more limited

ability to speak English among Asian American adults in contrast with their younger

counterparts has posed a significant barrier to their inclusion in research studies and national

surveys (Wong et al., 2007; Zane & Huh-Kim, 1998). Third, as noted above, most published

research has reported data for Asian Americans as a composite group, providing little

information on differences in alcohol-use patterns among subgroups of the population (Fong &

Tsuang, 2007; Kuramoto, 1997; Varma & Siris, 1996; Zane & Huh-Kim, 1998). “The paucity of

systematic collection of disaggregated Asian American and Pacific Islanders (AAPI) data leads

to a lack of information on the health status, treatment, and service delivery to various AAPI

subgroups” (Louise, 2001, p.176).

The current study addressed the shortcomings in prior research in a number of ways. First,

researchers argue that both level of acculturation and acculturative stress are relevant factors to

consider in relation to alcohol use. Therefore, the current study incorporated consideration of

both acculturative stress due to family cultural conflict and racial/ethnic discrimination and

acculturation as predictors of alcohol consumption, and also considered the potential for the

variables religiosity and social support to moderate these relationships. In particular, this study

built on a study by Chae et al. (2008) which examined the relationship between routine

experiences of unfair treatment and racial/ ethnic discrimination and life-time alcohol use

disorders. That study included both alcohol abuse and alcohol dependence disorders and used the

National Latino and Asian American Study (NLAAS) data. Unfair treatment was assessed as

frequency of routine experiences of unfair treatments, while racial/ethnic discrimination was

assessed as Asian Americans’ perceptions of discrimination. The NLAAS analyses revealed that

unfair treatment was significantly related to a history of alcohol use disorder. The current study

extended and built upon the Chae et al. (2008) findings, using the same NLAAS data set but

incorporated analyses of a greater number of relevant variables (i.e., family conflict, social

support, and religiosity) and examined more complex relationships as predictors of alcohol use.

Second, this study used a representative adult population, rather than one limited to a

young college sample. Third, analyses were conducted separately among different ethnic

subgroups, which allowed for more accurate and targeted conclusions and enable comparisons

across ethnic subgroups. Prior studies, including Chae et al. (2008), have not examined subgroup

differences but rather have adjusted these out of the analyses. In contrast, this study conducted

separate analyses for Chinese, Vietnamese, and Filipino Americans.

In sum, this study is aimed to provide a better understanding of how the key factors of

acculturation and acculturative stress relate to alcohol use and how these relationships are

modified by social support and religiosity within subgroups of this population. Overall, the

analyses in this study aimed at filling knowledge gaps about intergroup heterogeneities among

Asian Americans. They will provide information necessary for the design of effective ethnically-

specific and culturally-tailored interventions for improving the health status of both specific

subgroups and Asian Americans on the whole.

Significance of the Proposed Study for Social Work

In 2003, 22 million Americans were identified as having substance abuse problems, but,

only 3.5 million received treatment services (SAMHSA, 2003). One explanation for this gap in

service is shortage of adequately qualified professionals and appropriate treatment options

(Kaplan, 2005). According to the National Association for Alcoholism and Drug Abuse

Counselors (NAADAC; now known as The Association for Addiction Professionals), 22% of its

members are licensed social workers (Kaplan, 2005). Expanding the number and expertise of

social workers trained to address substance abuse issues could potentially help close the gap

between need and available treatment.

While there are relatively fewer social workers specializing in addiction compared to

other mental health treatment providers, the field has made efforts to enhance the study of

addiction (Straussner, 2001). For example, in 1995, the National Association of Social Workers

(NASW) recognized the importance of treating addiction by establishing a specialty section

focusing on the study of alcohol, tobacco, and other drug use, and the association now offers a

clinical credential in the specialty (Straussner, 2001). This development, in turn, has fostered

interest in related topics within the social work field including the relationship between ethnicity

and substance abuse. While this is an important development, much remains to be done to bring

the field of social work in line with the needs of the Asian American community. The current

study will contribute empirically-based knowledge about alcohol use among Asian Americans

and will promote sensitivity to cultural and ethnic diversity in the field of social work and

substance abuse treatment.

Moreover, social work has a distinguished history of working to address the needs of

immigrant populations, ethnic minorities, and people affected by alcohol use and abuse. As the

number of Asian Americans in the United States continues to increase, social workers need to be

prepared to address increased use of alcohol in this population. By testing a comprehensive

model of alcohol use that incorporates both protective and risk factors, the study will provide

knowledge to improve the understanding of the lives of ethnic minority groups who are

acculturating to the mainstream society and will potentially contribute to improved assessment

and treatment of Asian Americans.

In addition, Asian Americans tend to underutilize and prematurely terminate mental

health services (Lin & Cheung, 1999; Yu, Clark, Chandra, Dias, & Lai, 2009), a trend that

reflects in part a lack of appropriate culturally-sensitive services. The results of the study with

Asian Americans can inform social work interventions at individual, family, and community

levels for this rapidly growing population. Furthermore, the comparative study of ethnic

subgroups will provide information to inform culturally relevant assessments and interventions

for members of specific subgroups. Overall, this study will provide much needed data to improve

understanding of the experiences and needs of the rapidly growing but understudied Asian

American population.

Chapter II

Literature Review

Relevant literature is summarized pertaining to alcohol use among Asian Americans and

to this current study exploring factors that contribute to alcohol consumption within three ethnic

subgroups of this population. First, alcohol consumption is discussed, both in relation to

associated health consequences and in regard to measurement approaches relevant to the

proposed research. Second, the Asian American population is characterized as a whole and the

three ethnic subgroups that are the focus of this study are described with respect to cultural and

historical differences. What is known about alcohol consumption among Asian Americans is also

be summarized. Third, the literature on some factors that may contribute to or moderate alcohol

consumption is reviewed, with attention to acculturation, acculturative stress (discrimination,

family conflict), social support, and religiosity. Lastly, the conceptual framework for

understanding alcohol use that emerges from the reviewed studies is introduced.

Alcohol Consumption

Health consequences. Alcohol consumption contributes to a range of acute and chronic

health problems, including injuries from auto and other accidents, alcohol abuse and dependence

disorders, cancer, and cardiovascular disease (Dawson, Grant, & Hartford, 1995; Midanik, Tam,

Greenfield, & Caetano, 1996; Rehm, Gmel, Sempos, & Trevisan, 2003; Room, Barbor, & Rehm,

2005). The Epidemiological Catchment Area Study (ECAS) reported the rate for lifetime

occurrence of alcohol abuse or dependence as 13.5 % (Kessler et al., 1994). Overall, research

supports the expected positive relationship between alcohol use and alcohol use disorders

(Archer, Dawson, & Grant, 1995; Caetano, Tam, Greenfield, Cherpitel, & Midanik, 1997;

Kessler et al., 1994). Caetano, Tam, Greenfield, Cherpitel, and Midanik (1997) found that the

consumption of five or more drinks in one day during the previous 12 months translated into a

six-fold risk of being alcohol dependent.

In addition, Russell and colleagues (2004) reported a liner relationship between increased

quantity and frequency of alcohol consumption and number of self-reported problems. For

example, binge drinking and heavy drinking have been associated with increased health

problems among drinkers, especially fatal and nonfatal injuries (CDC, 2006). Similarly, Rehm,

Room, Graham, et al. (2003) conducted a meta-analysis of the relationship between alcohol

consumption and a variety of diseases and found volume of alcohol intake to be associated with

increased risk for most diseases, including cancers of the mouth, oropharynx, esophagus, liver,

and breast as well as epilepsy, hypertensive diseases, hemorrhagic stroke, and cirrhosis.

In contrast, light to moderate alcohol consumption has been shown to have a beneficial

effect on the cardiovascular system compared to lifetime abstention or heavy drinking (Rehm,

Gmel, Sempos, & Trevisan, 2003). However, Rehm, Gmel, Sempos and Trevisan (2003) caution

that longitudinal analysis has failed to confirm this beneficial effect. Moreover, Puddey, Rakic,

Dimmitt, and Beilin (1999) state that the conclusion of a beneficial effect of alcohol is not

"clear-cut" (p. 650) and suggest that the pattern of consumption needs to be evaluated and

considered more carefully to better understand the overall impact of alcohol on cardiovascular

risk.

Recently increased attention had been given to the alleged benefits of moderate drinking.

The definition of moderate drinking is highly subjective and depends on individuals and cultures,

and no universal definition exists (DuFour, 1999). In the United States, according to the Dietary

Guidelines (USDHHS, 2005), moderate drinking is defined as "no more than one drink per day

for women and no more than two drinks per day for men" (p. 44). However, since individuals

react differently to alcohol consumption depending on body weight, age, and other variables

(DuFour, 1999), even this definition is questionable. Thus, physiological differences need to be

taken into account when discussing the effects of alcohol on drinkers.

Certain biological characteristics make some people more susceptible to health problems

arising from alcohol use than others. Brooks, Enoch, Goldman, Li, and Yokoyama (2009)

recently reported that individuals who have a deficiency in the enzyme aldehyde dehydrogenases

2 (ALDH-2) carry a much higher risk of esophageal cancer from alcohol consumption than those

with fully active ALDH-2 and that even moderate drinking increased the risk for esophageal

cancer among those with the deficiency. In non-drinkers, ALDH-2 deficiency by itself did not

have an effect on risk of esophageal cancer. Importantly, it appears that an inherited ALDH-2

deficiency is common among Asian Americans, manifesting most often as a flushing response

when consuming alcohol. Therefore, even a moderate consumption of alcohol may pose a higher

risk of esophageal cancer for this population.

In addition, liver cancer is prevalent among Asian Americans (USDHHS, 2009). While

hepatitis B is the factor most strongly associated with liver cancer, alcohol consumption is

another important predictor. This suggests that alcohol use may be implicated in the high

incidence of liver cancer in this population.

In brief, along with other health problems, the higher prevalence of liver cancer and the

increased risk of esophageal cancer among Asian Americans who drink support the critical

importance of examining alcohol consumption patterns and contributing factors to alcohol use

within this population.

Measurement of alcohol consumption. Alcohol consumption can be measured in many

ways (Breslow, Guenther, & Smothers, 2006). Five types are commonly used: (1) frequency

measures; (2) quantity-frequency measures (QF); (3) graduated frequency measures; (4) short-

term recall methods; and (5) diary methods (Dufour, 1999). Reviewing all approaches to

measurement is beyond the scope of this review, but frequency and QF measures are discussed

briefly as they pertain directly to the current study. Frequency measures query respondents in

regard to how much they typically drink within a specified timeframe (e.g., the past year), giving

them predetermined categories from which to choose. Since the actual amount of alcohol

consumed on each drinking occasion is not assessed, a frequency measure alone cannot capture

the total volume or average amount consumed (Rhem, 1998).

In contrast to the frequency measure, a QF measure queries the amount of alcohol

consumed in addition to frequency (Breslow et al., 2006; DuFour 1999), allowing calculation of

total volume of alcohol consumption and providing information on drinking patterns. Because of

these merits, QF measures are the most widely used instruments for measuring drinking in most

countries, including the United States (Breslow et al., 2006; DuFour, 1999), and will be used in

this study.

Description of the Asian American Population

This section includes three parts: a brief description of the Asian American population as

whole, a summary of Chinese, Filipino, and Vietnamese subgroups in terms of distinct history

and cultural features, and a synopsis of what is known about the prevalence of alcohol use

among Asian Americans.

Asian Americans are the fastest-growing ethnic minority in the United States (Hahm,

Lahiff, & Guterman, 2003). From 1990 to 2000, this population increased by 46 %, as compared

to 13 % for the general population as a whole (Wong et al., 2007). This growth is expected to

continue. While Asian Americans comprised just 4.2 % of the total U.S. population in 2000

(Reeves & Bennett, 2004), by 2050 it is projected that they will comprise 11 %, about 41 million

people (Arliss, 2007).

In general, Asian cultures are considered to be more collective in orientation in

comparison to more individualistic western cultures, and, at the most general level, the Asian

American population can be expected to reflect this distinction. Collective values include an

emphasis on maintaining harmonious relationships with others and exerting pressures on

individuals to subordinate satisfaction of individual needs to the needs of family and community.

Nevertheless, while this characterization may generally hold across Asian cultures and Asian

American immigrants, considering the Asian American population as a whole without taking

into account subgroup distinctions risks missing important cultural differences of potential

relevance to alcohol consumption.

Asian Americans are a heterogeneous group encompassing more than 30 ethnic

subgroups (Loue, 2003; Uba, 1994). The six dominant subgroups in order of their prevalence

are: Chinese (23.8%), Filipino (18.3%), Asian Indian (16.1%), Vietnamese (10.8%), Korean

(10.5%), and Japanese (7.8%) (Asian American Federation of New York [AAFNY], 2004).

These subgroups vary greatly with respect to socioeconomic status, migration patterns, language,

and political inclinations (Lee, 1997; Loue, 2003). About 70% of Asian Americans living in the

United States were born abroad and continue to be influenced by the cultural norms and values

of their native countries (Lai & Arguelles, 2003). Nearly two thirds of all Asian Americans still

speak an Asian language at home (USDHHS, 2001).

Helms and Cook (1999) defined ethnicity as "the national, regional, or tribal origins of

one's oldest remembered ancestors and the customs, traditions, and rituals (i.e., subjective

culture) handed down by these ancestors, which among the ethnic group’s members, are assumed

to their culture” (p. 19). Further, according to Yancey, Aneshensel, and Driscoll (2001), ethnicity

distinguishes individuals based on their inclusion in groups whose members have common social,

cultural, and historical heritage. In line with the aforementioned definition of ethnicity,

subgroups of Asian Americans have distinct cultures. Those of Chinese, Filipino, and

Vietnamese American subgroups are described below.

Chinese. According to the U.S. census, 2.7 million Chinese Americans represent 23% of

the total Asian American population in this country (Barnes & Bennett, 2002). The Chinese were

the first group of Asian Americans to come to the United States in large numbers (Lee & Mock,

2005). Most of them came as manual labor for the construction of railroads in the mid 1800s

(Lee, 1997). Racial and ethnic antagonism and xenophobia against these early immigrants led to

the passage of the Chinese Exclusion Act of 1882, which barred Chinese laborers and their

relatives from entering the United States (Lee, 1997).

Currently, most Chinese Americans reside in California, with the next largest populations

in New York and Hawaii (Lee & Mock, 2005). As of 2000, about 47% of Chinese Americans

were foreign born (Lai & Arguelles, 2003) and about 50 % did not speak English well (Reeves &

Bennett, 2004). While no single native language is shared by all Chinese immigrants, the most

commonly spoken dialects are Cantonese and Mandarin.

Traditional Chinese culture places strong emphasis on harmonious interpersonal

relationships and interdependence. Interactions among family members are governed by

hierarchy, obligation, and duty (Lee, 1997). Families are patriarchal, with males filling the

dominant roles and wives subservient to their husbands. Among Chinese Americans, the most

common religions are Buddhism and Christianity (Lee & Mok, 2005), although Confucianism

and Taoism also represent important influences on people’s behavior.

Filipinos. Filipinos are a multicultural people with elements of Chinese, Spanish,

Malayan, Indonesian, and South Asian heritage. The Philippines were at various times colonized

by the Americans, the Spanish, and other Asian powers (Nadal, 2000). This history has

contributed to a kind of "colonial mentality" (p. 102) that includes a sense of inferiority and

suspiciousness in relation to the colonizer (Sustento-Senriches, 1997).

Filipinos began migrating to the Unites States in the late 1880s. Compared to other Asian

Americans, they have the highest rate of English proficiency, largely due to their colonization by

the United States (Root, 2005). This, along with such factors as multigenerational households,

sharing of resources, and education, has helped Filipinos achieve one of the highest median

family incomes and lowest poverty levels of immigrant groups. Also, due to four hundred years

of Spanish colonization, over 80% of the Filipino population is Roman Catholic (Nadal, 2000).

The Filipino concept of family extends beyond the nuclear to include the clan and the

community (Sustento-Senriches, 1997). The family structure is hierarchical, based on respect and

responsibilities, and Filipino culture places great value on harmonious relationships (Sustento-

Senriches, 1997).

Vietnamese. Compared to Chinese and Filipino Americans, Vietnamese are relatively

recent immigrants (Wong et al., 2007). As a result of U.S. military involvement in Vietnam in

the 1960s and 70s, many came as involuntary immigrants (Wong et al., 2007), and large numbers

arrived after the end of the Vietnam War in 1975 (Sodowsky, Lai, & Plake, 1991). The growth

rate in the Vietnamese population from 1990 to 2000 was 82.7% (Xu, Ross, Ryan, & Wang,

2005). By 2002, there were about 1.2 million Vietnamese Americans in the U.S., representing

11% of the U.S. Asian population (Barnes & Bennett, 2002). This number is expected to grow to

nearly 4 million by the year 2030. A large portion of the Vietnamese American population is

foreign born, although there is now a generation that was born in the United States (Wong et al.,

2007). Still, according to the 2000 U.S. census data, 62.4% of Vietnamese Americans do not

speak English very well and/or at home (Barnes & Bennett, 2002).

China has had strong and extensive influence on Vietnamese culture and history (Leng &

Boehnlein, 2005). Chinese Confucianism, adopted by Vietnam, has governed Vietnamese society

for centuries (Leng & Boehnlein, 2005). Currently the Vietnamese most commonly practice

Buddhism and Catholicism, the latter a result of French colonialism (Lee & Mok, 2005). With

respect to family culture, more importance is placed on the family group than the individual.

Maintaining relationships of harmony with the environment and other people is also important.

In sum, while there are cultural similarities across these three ethnic subgroups of Asian

Americans including shared hierarchical family structure, and an emphasis on family-

centeredness, each group represents a different combination of history, geography, language, or

religion. As such, the experiences of these ethnic subgroups are likely to differ too in regard to

acculturation, acculturative stresses (family conflict and discrimination experience), social

support, and other factors that potentially contribute to or moderate drinking behavior. This

current study takes into account this cultural diversity within the Asian American population by

separately examining the how such variables interrelate in predicting alcohol consumption for

three distinct subgroups of Chinese, Filipino, and Vietnamese Americans. Studying alcohol

patterns in disaggregated Asian Americans samples will allow more precise testing of the

applicability of the proposed model of alcohol use.

Prevalence of alcohol use among Asian Americans. Estimates about the prevalence of

alcohol use among Asian Americans vary, depending in part on how the population has been

defined and sampled and on whether subgroups have been queried separately. In general,

epidemiological studies that treat Asian Americans as one group report lower rates of alcohol use

in this population compared with other ethnic groups (Caetano, Clark, & Tam, 1998; Lee et al.,

2003; Loue, 2003; Price et al., 2002). However, the few studies that have examined patterns of

alcohol use in different ethnic subgroups reveal a more complex picture (Lee et al., 2003; Griffin,

Mosher, Rotolo, & Drapela, 2004; Wong et al., 2007).

Most past research on racially or ethnically based differences in alcohol use has focused

on Hispanic Americans, African Americans, and Whites, while either excluding Asians or

relegating them to a category of “others” (Lee et al., 2003). However, recent national studies on

alcohol use have reported data for Asian Americans, treating them as a single group. For

example, a 1998 National Household Survey on Drug Abuse (NHSDA) study reported that,

based on frequency analyses, Asian Americans as a group had lower rates of alcohol

consumption than the general United States population; 53 % of Asian Americans consumed

alcohol compared to 56 % of non-Asian Americans (Griffin at al., 2004). A 2003 SAMHSA

publication provides a more complex picture of substance use among Asian Americans with

analyses by ethnic subgroup. That study reported dramatic differences among groups in alcohol

and other drug use; lifetime prevalence of alcohol use among adults ranged from 51.5% for

Asian Indians to 83.9% for the Japanese, and past-30-day alcohol use ranged from 23.4% for

Filipinos to 45.3% for the Japanese (Griffin et al., 2004). The fact that the same study found that

Asian Americans as a group consumed less alcohol than the U.S. population in general

underscores the importance of more nuanced subgroup analyses.

Clinical and anecdotal evidence further suggests that alcohol abuse is a significant

problem within the Asian American community (Zane & Sasso, 1992). Alcohol abuse and

dependence disorders have been reported as the most common psychiatric disorders affecting

Asian Americans (Chang, 2002). According to the National Asian Pacific American Families

Against Substance Abuse (NAPAFASA, 2005), alcohol use is both prevalent and increasing

within this population, and those Asian Americans who do drink typically drink more per day

than any other racial/ethnic group. The implications of these patterns are potentially serious since

Asian Americans with alcohol dependence appear to be at a greater risk for alcohol-related

illness such as cancers and alcohol-induced asthma (Sakai, Ho, Shore, Risk, & Price, 2005). In

addition, it appears to be important to examine the changing nature of alcohol use among the

Asian American population over time: Longitudinal data indicate that the prevalence of alcohol

use disorders among Asian Americans doubled from 1990-1991 to 2000-2001 (Grant et al.,

2004).

Community-based studies of alcohol use have reported less consistent findings in rates of

alcohol use among Asian Americans than have broader national studies (Chi, Lubben, & Kitano,

1989; Wong et al., 2007). For example, a study by Chi, Lubben, and Kitano (1989) showed that

heavy drinking among Asian Americans—defined as at least five drinks during a single drinking

occasion— was similar to that of the general U.S. population with rates of heavy drinking among

Japanese and Korean Americans at 28.9% and 25.8%, respectively. In contrast, a 2007 National

Survey on Drug Use and Health (NSDUH) study reported that the rate of heavy drinking among

Asian Americans as a single group was 12.6% (SAMHSA, 2007). In another study, which used a

community-based methodology, Wong et al. (2007) reported that the current alcohol-use rate

(defined as at least one drink in the past 30 days) for Vietnamese Americans was 60.3%,

considerably higher than the 56.1% for Whites found in a 2007 NSUDH report.

There are numerous reasons why results of epidemiological studies may not accurately

reflect the full scope of alcohol use among Asian Americans. These include (1) inappropriately

treating Asian Americans as a homogenous group, (2) the underrepresentation of Asian

Americans in treatment facilities from which research samples are drawn, (3) biases introduced

by self-report methodologies, (4) lack of culturally appropriate measurement, and (5) the myth of

‘model minority’ (Ja & Aoki, 1993; Subramanian & Takeuchi, 1999; Zane & Huh-Kim, 1998).

Each of these reasons is elaborated below.

First, differences in rates of alcohol use may be the result of reporting data on Asian

Americans as if they represented a homogenous group (Caetano et al., 1998; Kuramoto, 1997;

Makimoto, 1998; Subramanian & Takeuchi, 1999; Varma & Siris, 1996; Wong et al., 2007). A

report by the Surgeon General (USDHHS, 2001) noted that categorizing all Asian American

groups under one heading has resulted in misconceptions of lower rates of alcohol use, and a

lack of research devoted to or resources provided for this population. However, as mentioned

earlier, rates of alcohol use vary within subgroups of Asian Americans (Price et al., 2002; Wong

et al., 2007).

Second, many epidemiological studies have been conducted in substance abuse treatment

settings where few if any Asian Americans are located. The underrepresentation of Asian

Americans in such centers has been well-documented (Caetano et al., 1998; Ja & Aoki, 1993).

For, example, while Asian Americans represented 4.2% of the total U.S. population (Reeves &

Bennett, 2004), in 2003 they constitute just 1.1 % of the nearly 1.7 million admissions to

publicly funded alcohol-abuse treatment program (National Institute on Drug Abuse [NIDA],

2005). The underrepresentation probably results from the reluctance of Asian Americans to seek

treatment for alcohol-related problems because of fatalistic views of having no personal control

over outcomes (Zane & Kim, 1994), cultural stigmas (e.g., losing face), and language barriers

(Catetano et al., 1998; Ja & Aoki, 1993; Ja & Yeun, 1997; Mercado, 2000).

Moreover, many research studies have relied on self-report measures or interviews that

may lead to underreporting of alcohol consumption because of a strong culturally-based stigma

against substance use (Ja & Aoki, 1993; Subramanian & Takeuchi, 1999; Zane & Kim, 1994).

Furthermore, many of the studies have failed to use culturally-appropriate measurement tools

and/or provide translation of the items or questions (Zane & Huh-Kim, 1999). Even when

translated measures are available, few studies evaluate the conceptual equivalence of the

translated measures with the originals (Zane & Huh-Kim, 1999). Finally, the stereotypical notion

of Asian Americans as reserved, successfully assimilating into the dominant culture, and high

achieving model minority members, may contribute to erroneous perceptions of their alcohol use

(Ja & Aoki, 1993; Loue, 2003; Mercado, 2000; Subramanian & Takeuchi, 1999).

Taken as a whole, the literature suggests that problems of alcohol use in the Asian

American community have probably been underestimated. Because of the misconception of

Asian Americans as a “model minority” and the lower prevalence rates of alcohol use for the

Asian American population as a whole, little attention has been given to the study of alcohol

consumption and its determinants among Asian American groups. The limited available

literature nonetheless highlights the potential importance of disaggregating the Asian American

population into subgroups for research purposes. Finally, this population is no more immune to

alcohol use than any other (Chi et al., 1989; Fong & Tsuang, 2007); Asian Americans share the

same negative consequences of drinking alcohol with other ethnic groups and, as elaborated

earlier, may be at greater risk for certain diseases. Clearly, a focus on alcohol use within this

population is overdue. It is time to move beyond debating about rates of alcohol use and to

examine underlying factors contributing to alcohol use and related problems within various

segments of the Asian American population.

Relevant Contributory Factors to Alcohol Use

Research has focused on several potential contributory factors in relation to alcohol use.

Some researchers have emphasized the role of biological factors (Matsyuoshi, 2001; Wall &

Ehlers, 1995). Others have pointed to psychological triggers such as trauma, while still others

have asserted the importance of socio-cultural factors, such as a person’s cultural background

and degree of acculturation (Caetano et al., 1998; Chen, 2003; Johnson & Nagoshi, 1990;

Makimoto, 1998). Overall, alcohol consumption appears to be multi-determined—the combined

result of biological, socio-cultural, and psychological influences (Straussner, 2001). Biological

and socio-cultural factors that pertain to an understanding of alcohol consumption in Asian

American population and to the conceptual model developed for this current study are reviewed

below.

Biological factors. Many studies have explored the role of biological factors in Asian

Americans’ alcohol use (Luczak, Elvine-Kreis, Shea, Carr, & Wall, 2002; Matsuyoshi, 2001;

Wall & Ehlers, 1995), suggesting the prevalence of ALDH-2 deficiency may account for their

apparently lower rate of alcohol consumption. The deficiency gives rise to a flushing response

when alcohol is consumed, characterized by a reddening of the face and torso and an increase in

skin temperature (Caetano et al., 1998; Matsuyoshi, 2001). ALDH2 is a liver enzyme involved in

the breakdown of alcohol, without which the oxidation of acetaldehyde occurs more slowly,

causing a higher blood acetaldehyde level and consequently flushing when alcohol is consumed

(Wall & Ehlers, 1995). People of Asian heritage are more susceptible to this negative

physiological reaction to alcohol compared to other ethnic groups (Luczak et al., 2002).

Not all Asian Americans experience the flushing reaction, and the prevalence of flushing

differs from one Asian group to another (Austin, Prendergast, & Lee, 1989). Although the

response may mitigate alcohol consumption, it is inadequate to explain the lower rates of alcohol

consumption in Asian Americans compared to other ethnic groups (Au & Donaldson, 2000;

Johnson & Nagoshi, 1990). For example, although in some studies Asian Indians have higher

levels of flushing compared with other Asian groups, they also consume more alcohol (Stewart,

1964, cited in Peele 1986). Hence other contributory factors must also be considered to

understand alcohol use among Asian Americans (Johnson, Nagoshi, Ahern, Wilson, & Yuen,

1987; Sue, Zane, & Ito, 1979; Zane & Huh-Kim, 1998).

Socio-cultural factors. There are several socio-cultural factors that may contribute to

alcohol use among Asian Americans of any subgroup. Only some of these factors are the focus

of this review: acculturation, acculturative stress (including discrimination and family conflict),

social support, and religiosity.

Acculturation. Acculturation has emerged as an important construct to explain health

behavior of ethnic minorities (Cabassa, 2003; Trimble, 2003), and many studies have examined

the relationship between acculturation and alcohol use. In this section, acculturation is defined,

conceptual and methodological approaches to measurement of acculturation are described, and

available literature on the relationship between acculturation and alcohol use among Asian

Americans is summarized. The review focuses on acculturation and acculturative stress models

with particular attention to acculturative stressors of discrimination and family conflict.

Acculturation is an important variable in studies of the well-being of ethnic minorities

and immigrants (Trimble, 2003; Zane & Mak, 2003). Specifically, acculturation refers to the

process by which the social, psychological, and cultural lives of ethnic minorities and

immigrants including their beliefs and behaviors, are affected and changed by the mainstream

culture in which they live (Berry, 1997). The construct describes the impact on beliefs and

behaviors that results from continuous contact between individuals from different cultures

(Caetano & Clark, 2003; Zane & Mak, 2003).

The pressure to accommodate to the larger culture is a complex and powerful force in the

lives of all ethnic minority individuals (Berry, 2003; Caetano & Clark, 2003). The acculturation

experience of new immigrants is shaped by their country of origin and the circumstances of

migration (Cabassa, 2003). The process of acculturation, however, is not confined to immigrants

alone; second and third generations born into families whose cultures are different from the

dominant one also face ongoing acculturation pressures (Zimmerman, Vega, Gil, Warheit,

Apospori, & Biafora, 1994).

A comprehensive literature review conducted by Gilbert and Cervantes (1986) gave raise

to two related models of the relationship between alcohol use and acculturation: an acculturation

model and an acculturative stress model. The acculturation model predicts that the drinking

pattern of an individual will resemble that of the general U.S population as the individual adopts

mainstream society's norms and culture. The acculturative stress model, on the other hand,

predicts more alcohol consumption by an individual as he or she is exposed to stressors which

occur during the acculturation process.

Models of acculturation. Whether acculturation is best understood and measured on a

uni- or multi-dimensional basis has been debated over time, reflecting shifting definitions of the

construct (Trimble, 2003). When viewed as a one-dimensional process, an individual’s

acculturation is seen as moving along a single continuum from conformity to the ethnic culture

of origin to adaption of the dominant culture (Gordon, 1964). Proximity to one cultural pole

implies distance from the other.

An alternative model proposes that acculturation is a bi- or multi-dimensional process,

best understood with reference to two distinct and independent dimensions (Berry, 2003). The

first dimension reflects the individual’s relationship to his or her culture of origin, ranging from

strong adherence to total rejection. The second dimension reflects the adaption by the individual

of the values, attitudes, and behaviors of the dominant culture, and similarly ranges from full

participation to complete rejection.

Berry’s multi-dimensional model defines four quadrants that representing distinct

acculturation styles: assimilation, integration, separation, and marginalization (Berry, 2003).

Assimilation refers to the complete absorption of the new culture and relinquishment of the

culture of origin. Integration refers to embracing and valuing both the original and the new

culture. Separation refers to adhering to the original culture while rejecting and avoiding the

dominant one. Finally, marginalization refers to the acculturation style of those who neither

adopt the new culture nor maintain their culture of origin.

Measuring levels of acculturation and acculturative stress. Acculturation measures vary

in terms of whether they are based on uni- or multi-dimensional models and on the domains of

cultural change they assess. Uni-dimensional measure includes proxy measures and uni-

dimensional scales. The proxy measurement approach is based on the assumption that degree of

acculturation can be approximated by assessing the cultural minority member’s amount of

exposure to the dominant culture. A proxy measure typically consists of a response to a single

question, such as duration of residence in the host country, generational status, English-language

proficiency, and age at time of immigration (Salant & Lauderable, 2003). Proxy variables and

their measures assume a uni-dimensional model of acculturation.

Unlike individual proxy measurements, uni-dimensional scales of acculturation typically

include multiple items that tap a variety of cultural domains (Zane & Mak, 2003). These scales

allow classification of individuals along a continuum ranging from low to high levels of

acculturation, depending on the degree to which they have adopted values, beliefs, or behaviors

of the mainstream culture. An example is the Suinn-Lew Asian Self-Identity Acculturation scale

(SL-ASIA) which contains items about language use, ethnic identity, and personal preference for

one culture or the other.

In contrast to uni-dimensional measures, multi-dimensional measures allow for separate

assessments of an individual’s adherence to both their ethnic culture and the dominant one

(Berry, 2003; Cabassa, 2003). Separate scores for each culture are then used to classify the

individual into one of the four acculturation categories described above: assimilation, integration,

separation, and marginalization. Examples of multi-dimensional measurements include the

Acculturation Rating Scale for Mexican-Americans-II (ARSMA-II; Cuellar, Arnold, &

Maldonado, 1995) and the Bi-dimensional Acculturation Scale (BAS; Marin & Gamba, 1996).

In one example of research using multi-dimensional measures to study Mexican

Americans, Cuellar, Arnold, and Maldonado (1995) found a significant link between

acculturation and generational status: Mexican orientation scores decreased in a linear trend with

each sequential generation, whereas Anglo orientation scores increased with each generation. In

addition, language use, a uni-dimensional measure, has been shown to correlate highly with more

comprehensive acculturation measures (Epstien, Botvin, Dusenbury, & Diaz, 1996; Gallagher-

Thompson et al., 1997), thus researchers may still find a uni-dimensional measure of

acculturation to be useful. Indeed, many researchers continue to conceptualize and measure

individual acculturation in a uni-dimensional way in their empirical studies (Gong, Takeuchi,

Agbayani-Siewert, & Tacata, 2003; Su & Wong, 2007; Takeuchi, Zane, Hong, et al., 2007;

Wong et al., 2007).

Researchers have made efforts to improve measurement of acculturation to better capture

the complexity of the process (Trimble, 2003), and many have suggested using multi-

dimensional models rather than uni-dimensional ones (Berry, 1997). Still, not even multi-

dimensional scales capture the dynamic nature of the acculturation process (Trimble, 2003). An

important component of acculturation may be the stress inherent in the process, for example, the

need to cope with discrimination and family conflict generated by cultural change.

Measures of acculturation stress are based on the assumption that stress is an inherent

part of acculturation (Berry, 2003). For example, such tasks as learning a new language or

finding a job inevitably challenge adaptive capabilities. Relative to the multitude of available

measures of acculturation, there are relatively few measures of acculturative stress, although

several researchers have made efforts to develop such measures (Chavez, Moran, Reid, & Lopez,

1997; Mena, Padilla, & Maldonado, 1987). Overall, a review of the literature leads one to

conclude that no definitively superior approach to measure either the acculturation or

acculturative stress has yet been demonstrated.

Acculturation scales appropriate for Asian Americans. Despite the availability of

measures of acculturation, those appropriate for use with Asian American are in short supply.

Zane and Mak (2003) conducted a content analysis of 23 acculturation scales. Of these, most

were designed for use with Hispanic Americans and only three were specifically designed for use

with Asian Americans: 1) the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA;

Suinn, Rickard-Figueros, Lew, & Vigil, 1987); 2) the Acculturation Scale for Southeast Asians

(AS-SEA; Anderson et al., 1993); and 3) the Asian Value Scale (AVS; Kim, Atkinson, & Yang,

1999). The SL-ASIA has been used with a broad array of Asian Americans including Chinese,

Japanese, and Korean Americans. The AS-SEA measures acculturation among Southeast Asian

Americans, including Cambodians, Laotians, and Vietnamese, while the AVS assesses value

orientations associated with East Asian societies. A review of the content of these three scales

revealed that standard measures applicable to all subgroups of Asian Americans were limited.

Zane and Mak (2003) reported that language use in one or more contexts (e.g., at home, with

friends, at work) was the most frequently assessed acculturation dimension with both Asian and

non-Asian ethnic minorities, consistent with the preponderance of language use and language

preference as core component of both uni- and multi-dimensional acculturation measures. The

general conclusion aptly applies to the specific study of Asian Americans, “no one measure

adequately samples the major behavioral and attitudinal domains related to acculturative change”

(p. 54).

Factors associated with acculturation. Language is a critical factor in the acculturation

process. The role of language is made apparent when considering outcomes for Filipino

Americans in comparison with other Asian American groups. Due to their history of American

colonization, Filipinos are more English proficient than other Asian American subgroups upon

immigration (Root, 2005) and tend to be more highly acculturated as well. Asian American

groups who have less exposure to English prior to coming to American tend to encounter serious

language barriers in the acculturation process. Such has been the case with Vietnamese

Americans, most of whom are recent immigrants (Wong et al., 2007), who arrived in the U.S.

after the Vietnam War (Sodowsky et al., 1991). Similarly, although the Chinese have migrated to

the U.S over the past 150 years, most in the current U.S. population are recent immigrants,

making language an important factor in their acculturation. In sum, differences in language

acquisition are crucially important in understanding the complex relationship between ethnicity

and acculturation.

Overall, it appears that the most important contributions to the rate and success of the

acculturation process are language acquisition and generational status, factors which interact

with ethnicity to produce a variety of trajectories for Asian Americans.

Acculturation and alcohol use. Acculturation may also play an important role in the

patterns of alcohol use among ethnic minorities. Both the acculturation and the acculturative

stress model have been proposed to address this relationship. The acculturation model posits that

alcohol use reflects the norms and practices of the society into which a person is being

acculturated, whereas the acculturative stress model posits that alcohol use increases in response

to the stresses accompanying the process of acculturation into a new society (Gilbert &

Cervantes, 1986). Research is summarized below relevant to the application of these models to

alcohol use.

Acculturation model for alcohol use. The acculturation model is based on the idea that

there is an ethnic culture that exists within the mainstream culture. Cultural transition occurs

between ethnic and mainstream cultures. According to the acculturation model, drinking

behavior of recent immigrants would be expected to mimic the drinking pattern in their home

country, but as they become more acculturate into the mainstream society, their drinking

behavior would come to resemble that culture. In Asian culture, drinking is generally social

rather than solitary, occurs in moderation and in prescribed settings, and, is usually accompanied

by eating (Matsyuoshi, 2001; Wall & Ehlers, 1995). With acculturation Asian Americans adopt

the more lenient and permissive drinking norms of the mainstream society.

Studies on the relationship between acculturation and alcohol use among Asian

Americans are summarized in Table 1. Although results have been inconsistent, the acculturation

model as a predictor of alcohol use has been generally supported. Some studies documented a

direct and positive relationship between acculturation and use of alcohol and alcohol-related

disorders (Gong et al., 2003; Liu & Iwamoto, 2007; Sue et al., 1979; Yi & Daniel, 2001) while

others fail to do so (Akutsu, Sue, Zane, & Nakamura, 1989; Kitano, Lubben, & Chi, 1988; Su &

Wong, 2006). These inconsistencies may reflect both methodological differences among studies

and a reliance on correlational and multiple regression analyses. For example, many have used

correlational and regression analyses but have not examined a complex path model of

determinants of alcohol use in relation to multiple acculturative factors among Asian Americans.

Table 1: Summary of available studies on acculturation and alcohol use among Asian Americans (in reverse chronological order) Authors Acculturation

measure Alcohol use measure Sample/design Findings Statistical Model

Liu & Iwamoto (2007)

 Asian Value Scale- Revised (AVS-R: Kim & Hong, 2004)

 Substance use (alcohol use, binge drinking behavior, marijuana use, cocaine, other illicit drug use) in the last month

 Asian American male college students.  Convenience sampling  Sample size=154

Chinese(n=40) Vietnamese (n=31) Filipino (n=23) Korean (n=17) Asian Indian (n=14) Japanese (n=12) other Asians (n=17)

 Asian Americans with higher adherence to Asian values drank less alcohol

 Logistic regression

Despuses & Friedman (2007)

 Modified version of Marin, Sabogal, Marin, Otero- Sabogal, & Perez- Stable(1987)  Three subscales:

language use, media, and ethnic social relations

 Alcohol per day  Alcohol per week  Binge drinking

 College students  Asian (n=153)

European (n=110) African (n=69) Hispanic (n=138) other (n=51)  Sample size=521

 Asian Americans with high acculturation reported to drink more than those with lower acculturation

 MANCOVA

Wong et al. (2007)

 Place of birth (US born vs. Foreign Born)  English-language

proficiency

 Use of alcohol in the past month

 Cambodian, Laotian, & Vietnamese Adults in Washington D.C. metropolitan area  Sample size=494

 Those who were born in U.S. were more likely than those who were foreign born drink alcohol

 Logistic Regression

Su & Wong (2006)

 Language spoken at home  Preference for

 Substance Use Checklist (19 items)

 College students in a private university in East Coast city.

 Those who preferred watching American TV/Movie were

 Correlation testing

eating American food and watching American TV/movie  Place of birth (US

born vs. Foreign born)

 use of substance in lifetime and in the past 30 days

 Sample size= 248 Asian American and Pacific Islanders.

more likely to drink alcohol  Foreign born Asians

were more likely to drink beer than U.S. born.  No association

between language at home and current drinker

Hendershot, MacPherson, Myers, Carr, & Tamara (2005)

 Suinn-Lew Asian Self-Identity Acculturation (SL- ASIA)

 Ever used alcohol in lifetime  Used alcohol in

past 30 days  Heavy drinking in

the past 2 weeks

 College students in Southern California  Sample size=428  Korean (n=205)

Chinese (n=223)  Longitudinal study

 Highly-acculturated Asian Americans were more likely to drink heavily.

 ANOVA

Gong, Takeuchi, Agbayabi- Siewert, & Tacata (2003)

 Length of time in US  Age at immigration  English

proficiency

 Alcohol dependence (Short form of the University of Michigan’s version of the Composite International Diagnostic Interview)

 Secondary data – the Filipino American Epidemiological Study in San Francisco or Honolulu.  Sample size= 1,818

Filipino immigrants.  Probability sampling

 Those who immigrated at early age were more likely to have alcohol dependence disorder than those who immigrated at older age.

 Multiple regression

Chung (2002)

 Generation status (U.S born vs. Foreign born)

 Alcohol consumption – average daily ethanol intake (current drinker, ex-drinker, & Abstainer)

 Adults  Chinese-, Japanese-,

Korean-Americans  Sample size=704  Secondary data -

National Longitudinal Alcohol

 U.S. born Asians consumed more alcohol than foreign born Asians.

 Multiple regression

 Alcohol dependence (lifetime)  Alcohol

abuse(lifetime)  Binge drinking  Socially

hazardous drinking

Epidemiological Study (NLAES) data of 1992

Yi & Daniel (2001)

 Modified version of the Suinn-Lew Asian Self-Identity Acculturation Scale

 Use of alcohol- current uses or nonuse

 College student at the University of Houston  Vietnamese  Sample size=412  Cross-sectional design

 Students who were more acculturated were more likely to drink than those with less acculturation

 Logistic regression

Akutsu, Sue, Zane, & Nakamura (1989)

 Contrasting Value Survey (60-items) (Conner, 1977)

 Frequency & Quantity of alcohol use (Abstainer, infrequent drinker, light drinker, moderate drinker, and heavy drinker)

 University students  Chinese (n=49)

Japanese (n=34) Caucasian (n=96)

 Acculturation was not related to alcohol consumption

 Hierarchical multiple regression

Johnson, Nagoshil, Ahern, Wislon, & Yuen (1987)

 Place of birth (US born vs. Foreign born)  Number of years of

residence in Hawaii

 Frequency & Quantity of alcohol use (Abstainer, former drinkers, and current drinkers)

 Chinese, Japanese, Filipino, Hawaiian, Hapa- Haoles, and Caucasian  Sample size=3,714  Cross-sectional design

 Chinese, Japanese, and Filipinos who were born in Hawaii were more likely to drink alcohol compared to those who were born in their home country.

 T-test and ANOVA

Sue, Zane, & Ito (1979)

 English-language proficiency

 Frequency & Quantity of

 College students  Chinese (n=23)

 Acculturation was related to increase

 MANOVA

 Socialization with American friends  Generation

(Parents/ grandparents – U.S born vs. Foreign born)

alcohol use (5 categories: abstainer/light, mild, moderate, heavy, and very heavy)

Korean (n=24) Caucasian (n=77)  Cross-sectional design

drinking levels.

Acculturation has been associated in some studies with increases in risky health-related

behaviors including alcohol use and drug use (Despues & Friedman, 2007; Gong et al., 2003;

Hahm et al., 2003; Liu & Iwamoto, 2007; Yi & Daniel, 2001), changes attributable to

incorporation of the values of the dominant culture through the acculturative process (Marin &

Gamba, 2002). Consistent with this reasoning, recent immigrants would be expected to show

rates of alcohol use similar to the rates in their home countries, with time shifting toward the

drinking patterns of the new dominant culture (Chung, 1990-1991; Gilbert, 1989; Kim, McLeod,

& Shantzis, 1995; Sue et al., 1979). Drinking patterns of subsequent generations of a particular

ethnic group would come to more closely resemble those of the general U.S. population (Chung,

1990-1991; Gilbert, 1989).

Research by Sue, Zane, and Ito (1979) supports these predictions: highly acculturated

Asian college students consumed more alcohol than their less assimilated counterparts. In their

study, acculturation was measured using three components: 1) socialization, based on the

percentage of an individual’s friends who were fellow Asian Americans; 2) level of proficiency

in the native language (Japanese or Chinese); and 3) the number of generations of family

residence in the United States. Not speaking one’s parents’ native language and longer familial

residence in the United States were significantly associated with increased alcohol consumption.

Similarly, Price et al. (2002), using the 1999 NHSDA and the 1992 National Longitudinal

Alcohol Epidemiologic Survey (NLAES), reported a positive relationship between acculturation

and alcohol use. Japanese Americans, who came from families that arrived as immigrants in the

early 20th century had the highest levels of acculturation among the ethnic subgroups in the study

and reported the highest rate of alcohol use (37.5%), closest to the rate among Whites (46.9%).

Conversely, Vietnamese Americans, the most recent immigrant group, were the least

acculturated and had the lowest rate of alcohol use (18.1%). Although sample sizes were too

small to allow definitive conclusions, the results support the link between acculturation and

alcohol use. Takeuchi, Zane, Hong, et al. (2007) also found that acculturation, as assessed via

English proficiency was positively associated with alcohol use disorders including both alcohol

use and alcohol dependences (DSM-IV diagnoses) among Asian Americans. The authors suggest

that English proficiency facilitate the expansion of social networks, increasing exposure to social

situations where drinking is involved.

Some studies report that ethnic minority individuals born in the United States, and

therefore assumed to be more acculturated, are more likely to use alcohol than those born

elsewhere (Brown, Council, Penne, & Gfroerer., 2005; Canino, Burman, & Caetano, 1992; Vega

& Gill, 1999; Wong et al., 2007). In their analysis of data from the 1999–2001 NSDUH, for

example, Brown, Council, Penne, and Gfroerer (2005) found that overall alcohol consumption,

past month alcohol use (defined as at least one drink in the past 30 days), and past month heavy

drinking (defined as five or more drinks on the same occasion on 5 or more days in the past 30

days) were lower for immigrants from China, Vietnam, and the Philippines in comparison with

their counterparts born in the United States. Chung’s dissertation (2002) similarly corroborates

the relationship between acculturation and alcohol use across Chinese, Japanese, and Korean

Americans. In this study, alcohol consumption was measured by average daily ethanol intake in

the previous month. Finally, Wong et al. (2007), using a community survey, found that U.S.-born

Southeast Asian Americans reported consuming three times more alcohol in the previous month

than their foreign-born counterparts.

Not all studies, however, have confirmed a relationship between acculturation and

alcohol use. Akutsu Sue, Zane, and Nakamura (1989) compared alcohol consumption,

acculturation, and physiological reactions to alcohol among Asians and Caucasians. When

demographic (i.e., age, gender, & body weight) and physiological factors were controlled, there

were no significant relationships between acculturation and alcohol use. Alcohol use was

measured by frequency and quantity of drinking; acculturation, by differences between Asian

and Western cultural values. Su and Wong (2006) also investigated the relationship between

alcohol use and acculturation, using three proxy measures of acculturation: place of birth,

preference for both American food and watching American television, and length of residence in

the U.S. The foreign-born Asian college students were more likely to be current drinkers than

their American-born counterparts.

As Sue and Nakamura (1984) have argued, acculturation reflects a complex set of

interactions between an individual’s native culture, mainstream American culture, and

generational status. Various factors may contribute to inconsistencies in research results. The

findings of any particular study are affected by how acculturation is defined and operationalized

(Caetano et al., 1998; Chen, 2003; Varma, & Siris, 1996). In addition, alcohol use measures vary

across studies, making comparisons difficult. In spite of inconsistencies related at least in part to

methodological differences, the acculturation model that proposes a direct association between

acculturation and alcohol use is generally supported.

Acculturative stress. As mentioned earlier, a concept closely related to that of

acculturation is acculturative stress (Caetano et al., 2008). Acculturative stress is defined “as a

stress reaction in response to life events that are rooted in the experience of acculturation” (Wei,

Heppner, Mallen, Ku, Liao, & Wu, 2007). Similarly, Castillo, Conoley, Brossart, and Quiros

(2007) defined acculturative stress as “the difficulties and stressors that arise during the

acculturative process” (p. 233). This reasoning suggests that acculturative stress is a part of the

acculturation process (Berry, 2006).

Caetano, Ramisetty-Mikler, and Vaeth (2007) assumed that levels of acculturation would

lead to acculturation stress and confirmed this relationship. More specifically, people with a

lower level of acculturation reported more stress. To explain this finding, the authors posited that

being less acculturated is more stressful because the individual experiences stronger tensions

between the ethnic culture and the host culture. In contrast, those who are more acculturated to

the host country have successfully adapted to values of mainstream society and, as a result, do

not experience as much acculturative stress. In that study, level of acculturation was indicated

by: daily use of and ability to speak, read, and write English and Spanish; preference for media

in English or Spanish; ethnicity of persons with whom individuals interacted (p. 1436). The

acculturative stress instrument covered topics such as conflicts with family because of changes in

values and adjustment problems.

Acculturative stress model for alcohol use. Alcohol use can be seen as one manifestation

of acculturation stress and the acculturative stress model posits that alcohol consumption is the

result of acculturative stress (Gilvert & Cervantes, 1986). According to this model, alcohol

consumption would be expected to increase among those struggling with cultural family conflicts,

discrimination, and other problems of cultural adjustment.

This acculturative stress model represents an adaption of the stress-coping model of

Lazarus and Folkman (1984) to the problems of cultural transition. In the stress-coping model,

stress occurs as a function of the relationship between an individual and an environment. An

individual’s encounter with environmental demands or a stressor causes the person to appraise

the situation. During the appraisal, an individual evaluates the stressor and available resources

for coping. Within this framework, alcohol use is seen as a coping strategy. Substantial empirical

studies have documented the relationship between stress and alcohol use (Horwitz & Davies,

1994; Sayette, 1999; Wills & Shiffman, 1985). In a comprehensive review of the research, Wills

(1990) concluded that a positive relationship between stress and alcohol use had been fairly

consistently demonstrated. Given the prevalence of stress in the process of adapting to a new

culture, the acculturative stress model has obvious relevance to potential alcohol abuse among

Asian Americans.

Like other ethnic groups, Asians in the United States often contend with challenges to

their economic survival, experiences of racism and discrimination, loss of extended family

support, cultural and family conflicts, marginalization, job dissatisfaction, and minority status. In

a review article, Subramanian and Takeuchi (1999) suggested that Asian Americans may use

alcohol to relieve psychological distress related to such stressors. Asian Americans tend to

underutilize mental health services due to the stigma attached to mental illness, a fact that may

further contribute to their vulnerability to using alcohol and drugs to relieve stress and manage

pain (Bhattacharya, 2005; D’Avanzo et al., 1994; McLaughin et al., 1987).

In spite of the logic and appeal of the acculturation stress model in regards to alcohol use,

few studies on the effects of acculturation on health behaviors have actually measured

acculturative stress (Caetano, Ramisetty-Mikler, Vaeth, & Harris, 2007). Studies that reported

acculturation as a risk factor for use of alcohol often assume that the relationship is based on the

stress of acculturation, without testing this assumption directly and empirically (Caetano et al.,

2007). In particular, several researchers have posited, based on their findings, that alcohol use is

associated with the stresses of coping with new cultural realities (D’Avanzo et al., 1994; Liu &

Iwamoto, 2007; Su & Wong, 2006; Vega & Gil, 1999). For example, D’Avanzo, Frye, and

Froman (1994) reported that Cambodian immigrant women used substances to relieve stress and

anxiety, but they did not assess acculturative stress in general or responses to specific stressors. It

is important to directly test rather than assume the underlying role of acculturative stress,

especially since according to the acculturation model an increase in drinking may be part of the

acculturation process itself, rather than a response to stresses encountered along the way (Black

& Markides, 1993; Caetano & Medina Mora, 1988).

In addition to not directly measuring acculturative stress as a construct, very few studies

to date have focused on specific acculturative stressors that may contribute to alcohol use,

although researchers, such as Recio Adrados (1993) have argued that the development of the

acculturative stress model would benefit from assessment of specific stressors. Among the most

important sources of acculturative stress are discrimination and family conflict (Castillo, Cano,

Chen, Blucker, & Olds, 2008; Salgado de Snyder, 1987; Yip, Gee, & Takeuchi, 2008), both of

which have been identified in the literatures as highly relevant to Asian Americans. The

following review explores these two important acculturative stressors as they pertain to the Asian

American population.

Discrimination. Asian Americans continue to experience discrimination due to their

ethnic group membership, although the topic has been overlooked in most research. Realistic

appraisal of the effects of discrimination has been impeded by perception of this group as a

“model minority” with Asian Americans viewed as having frequent educational and professional

success (Lee, 2003; Young & Takeuchi, 1998). Despite this stereotype, Asian Americans face

discrimination even when they are not recent immigrants (Liang, Li, & Kim, 2004). The

mainstream perception of Asian Americans as “perpetual foreigners” and “permanent aliens”

promulgates a view of Asian Americans as not “real” Americans (Liang et al., 2004). Members

of families who have been in the United States for several generations may still be seen as not

fully American.

Discrimination is a stressor and, as such, a risk factor for psychological distress and

alcohol use among racially and ethnically diverse populations (Jackson et al., 1996; Lee, 2003;

Noh, Kaspar, Hou, & Rummens, 1999; Yip et al., 2008). Whereas a number of studies have

examined the relationship between discrimination and alcohol use among African Americans and

Hispanic Americans, only a few have done so with Asian American samples (Gee, Delva, &

Takeuchi, 2007; Chae et al., 2008). One study by Gee, Delva and Takeuchi (2007) found that

everyday experiences of unfair treatment were associated with substance use among Filipino

Americans. In their study, unfair treatment was defined as “discriminatory behavior on the part

of institutions and individuals directed toward individuals with less power and the groups to

which they belong” (Gee et al., 2007, p.933). In another study, Chae et al. (2008), using data

from NLAAS, confirmed that Asian Americans who experience discrimination are more likely to

have alcohol disorders. These authors stated that substance use may be a means for ethnic

minority group members to attempt to cope with the psychosocial stressor associated with

discrimination.

Family cultural conflict. As the most proximal social environment, family has

increasingly been recognized as an important factor affecting individuals’ health status (Syme &

Yen, 2000). In traditional Asian cultures, the family is considered the central and most important

domain of one’s life. In such collectivist cultures, the strength of the family rests on the strength

of the individual members (Buki, Ma, Strom, & Strom, 2003). However, the needs of the family

are seen as more important than the needs of the individual. Family members are expected to

make sacrifices and decisions that are in the best interest of the family (Lee, 1997; Mercado,

2000; Uba, 1994).

Research indicates that many Asian American families experience and struggle with

intergenerational and cultural conflicts (Buki et al., 2003). In particular, it appears that greater

acculturation leads to more family conflict (Harachi, Catalano, Kim, & Choi, 2001), as family

members attempt to integrate disparate Asian and American cultural values and practices

(Bhattacharya, 2002; Buki et al., 2003). For example, when children become interpreters for their

parents who are struggling with English, this may threaten the hierarchical relationship of parent

and children and cause family discord.

In addition, Asian tradition emphasizes role differences between husbands and wives

(Lee, 1997; Uba, 1994), with the husband as the sole wage earner and the wife responsible for

housework and supporting her husband. However, economic realities often require women to

work outside the home causing gender role conflicts and potentially creating an imbalance in the

traditional structure of the family.

With respect to alcohol use, the few studies that have explored the role of family conflict

have focused on substance use among Asian American youth and young adults (Bhattacharya,

2002; Harachi et al., 2001). These studies found a positive relationship between intergenerational

conflicts between parents and their children and use of alcohol. For example, in two studies of

Asian Indian adolescents, Bhattacharya (1998 & 2002) found that family conflict was

experienced as stressful and was associated with increased substance use. In sum, it appears that

acculturation is often accompanied by experiences of discrimination and conflicts within the

family, stresses which may give rise to alcohol use as a means of coping.

Stress-buffering hypothesis: the role of social support and religiosity. There are factors

which mitigate the impact of stressors and which may lessen the risk of increased alcohol

consumption in the face of difficulties. According to the stress-buffering hypothesis, the

availability of social resources such as having supportive, close relationships will lessen the

impact of stressful events (Cohen & Pressman, 2004). In a seminal study, Cohen and Wills

(1985) performed a comprehensive review of the research on the relationship between stress and

social support and subsequently proposed two models of the protective effects of social support

in the context of stress. The simpler model, referred to as the main effect model, proposes that

social support is beneficial irrespective of the degree of stress that individuals are experiencing.

In other words, individuals exposed to both high and low levels of stress should benefit from

receiving social support which has been shown to enhance health and well-being. There is no

interaction between social support and stress proposed in this model. This prediction is in line

with Cohen and Wills’ (1985) general proposition that lack of positive social relationships is

psychologically detrimental.

The second model, referred to as the buffering model, proposes that social support

moderates the effect of stress on a person. According to the buffering model, social support is

beneficial for individuals experiencing stress because support reduces the effect of stressors

either by reducing the stress or by helping individuals to respond more adaptively. In other words,

this model proposes an interaction between stress and social support.

Recently, researchers using the framework of the stress-buffering model have identified

religion as a contributing source of social support (Ellison, Boardman, Williams, & Jackson,

2001; Ellison & Levin, 1998). Using the date from the 1995 Detroit Area study, Ellison,

Boardman, Williams, and Jackson (2001) found that frequent church attendance as one aspect of

religious involvement was related to mental health and conclude that religious involvement can

be a source of support, buffering the effects of stress and promoting well-being. Building on

these considerations, the current study examines both the main and buffering (moderating)

effects of social support and religiosity on alcohol use. The subsequent section provides further

review of the topic by focusing on the relationship between social support and stress and

between religiosity and stress.

Social support. Much research has provided evidence that social support mitigates the

effects of stress and decreases harmful health behaviors in a variety of populations (Brown,

Brady, Lent, Wolfert, & Hall, 1987; Cohen & Wills, 1985), including ethnic minorities (Chen,

Mallinckrodt & Mobley, 2002; Finch & Vega, 2003; Lee, Koeske, & Sales, 2004; Shen &

Takeuchi, 2002; Yoshikawa, Wilson, Chae, & Cheng, 2004). Individuals who have strong social

support networks tend to adapt more effectively and with less distress than those who have

weaker social support (Thomson, Flood, & Goodvin, 2006), and are less likely to engage in risky

health behaviors (Gottlieb, 1983; St. Lawrence, Brasfield, Jefferson, Allyene, & Shirley, 1994).

In addition, some studies have found an inverse relationship between social support and the use

of alcohol (Berkman & Breslow, 1983; Cohen & Lemany, 2007; Green, Freeborn, & Polen,

2001).

With respect to the relationship of acculturative stress and social support among Asian

Americans, Bhattacharya (2005) conducted a qualitative study of acculturative stress and risky

behavior among Indian Americans and found that social support was an influential contributor to

coping with acculturative stress. In another qualitative study, Chin, Lai, and Rouse (1991) found

that feeling isolated and lacking social support were associated with increased alcohol use.

However, these studies did not examine the effects of specific acculturative stressors. In a

quantitative study design, Noh and Kaspar (2003) examined whether racial/ethnic discrimination,

different types of coping strategies, and social support were associated with depression among

Korean Americans. The study revealed an interaction between racial/ethnic discrimination,

coping strategies, and social support in predicting depression.

Gee et al. (2006) examined whether social support could moderate the association

between discrimination and health condition among 2,241 Filipino Americans. Health condition

was measured using a composite score created from a check list of aliments including

hypertension, high blood pressure, and other heart disease. Discrimination was measured by

recording everyday experiences of unfair treatment due to participants’ ethnicity. Social support

assessed included access to both emotional and instrumental support. However, in contrast to the

above-mentioned research, this study did not find demonstrate an impact of discrimination-

related stress and health.

Finally, little research has been conducted on the relationship among specific

acculturative stressors, social support, and alcohol use among Asian Americans. Existing studies

of the relationship between social support and acculturative stress have yielded mixed results.

Religiosity. A growing body of studies has shown that religion and religiosity have both

direct and indirect protective effects against alcohol use (Chawla, Neighbors, Lewis, Lee, &

Larimer, 2007; Gong et al., 2003; Kerr-Correa, Igami, Hiroce, & Tucchi, 2007; Lubben, Chi, &

Kitano, 1988; Mullen, Blaxter, & Dyer, 1986; Yi & Daniel, 2001). This protective function has

been attributed to the fact that religion may serve as a resource in time of need and mitigate the

effects of life stressors. In addition, participation in religious activities can be an important

means of developing social networks (Garcia, 2005).

There is growing empirical evidence for the protective effects of religion in regard to

substance abuse in the Asian American population. Lubben, Chi, and Kitano (1988) found that

female Filipinos who were abstinent from alcohol frequently attended religious services.

Similarly, Yi and Daniel (2001) reported that religion had a beneficial influence on the drinking

patterns of Vietnamese Americans. However, these studies measured religion affiliation not

religiosity. A study by Gong et al. (2003) based on data from the Filipino American

Epidemiological Study (FACES) found that greater religious involvement was associated with

reduced risk for alcohol dependence among Filipinos Americans. Religious involvement was

operationalized as attending religious services, participating in activities of a religious nature,

and participating in private religious activities. Other empirical research has also demonstrated

that religiosity buffers the relationship between stress and alcohol use (Siegel, Anderman, &

Schrimshaw, 2001; Wills, Yaeger, & Sandy, 2003).

Overall, an important premise in regard to the link between social support/religiosity and

stress is that stressors are harmful only when coping resources are inadequate. For immigrants

and ethnic minorities, one key stressor is acculturative stress, and therefore it is important to

understand how it interacts with the social support and religiosity variables discussed above.

Despite the demonstrated links between stress and social support and stress and religiosity, few

empirical studies have examined the role of social support and religiosity in coping with

acculturative stress. Rather, most studies on stress have focused on traumatic stressors. In order

to understand how acculturative stress and social support and religiosity influence alcohol use in

the Asian American population it is important to consider that demands must exceed resources to

produce a negative outcome. As mentioned earlier, alcohol use can become a coping strategy

when social resources are inadequate to reduce stress (Vega, Zimmerman, Warheit, & Gil, 2003).

Thus, research is needed to develop an understanding of how acculturative stress and social

support and religiosity influence alcohol use in this population so as to inform future prevention

and intervention efforts.

Summary

The literature review presented identified social factors of acculturation, acculturative

stress (discrimination and family conflict), social support, and religiosity as associated with

alcohol use. On the one hand, it appears that greater levels of acculturation are positively

associated with alcohol use among some Asian American populations. On the other hand, other

studies suggest that Asian Americans drink alcohol to cope with the stress they encounter during

the acculturative process. Substantial research findings have identified discrimination and family

conflict as relevant acculturative stressors. However, currently there is limited research that takes

into consideration the effects of both acculturation and acculturative stress and examines role of

protective factors such as social support and religiosity. Most studies have typically examined a

simple direct relationship between acculturation and alcohol use and few have explored the

relationship of acculturation and acculturative stress as they may interact to affect drinking

behavior. This absence underscores the importance of developing a comprehensive model to

explain alcohol use among Asian Americans.

The current study proposes and then tests a model of how crucial variables of

acculturation, discrimination, family conflict, social support, and religiosity interact to affect

alcohol use within three subgroups of the Asian American population.

The conceptual framework for this study is shown in Figure1. This model is derived from

acculturation and acculturative stress model as applied to an investigation of how socio-cultural

factors may contribute to alcohol use among Asian Americans.

Figure 1. Proposed conceptual model for Asian Americans’ alcohol use

Chapter III

Method

This chapter presents the research questions, hypotheses and then the methodology for

the study, including date source and sample, method of sampling, study procedures, measures,

analytic plan, and ethical issues.

Statement of Research Questions and Explored Hypotheses

This current study has two research aims. Each aim is elaborated below in terms of

general questions and specific hypotheses. The first aim of this study is to describe patterns of

alcohol use within the Asian American subgroups. The second aim is to explore predictors of

alcohol use for three separate Asian subgroups: Chinese, Filipino, and Vietnamese Americans.

Questions and hypothesis to be addressed include:

1. What drinking patterns are found among subgroups of Asian Americans?

2. Is acculturation associated with alcohol use?

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that

Asian Americans who are more acculturated drink more than Asian Americans who are

less acculturated.

3. Are acculturative stressors (unfair treatment, perceived racial/ethnic discrimination and

family cultural conflict) associated with alcohol use?

Hypothesis 3.1: Unfair treatment and racial/ethnic discrimination have a direct effect on

alcohol use. It is hypothesized that Asian Americans who experience more unfair

treatment and perceive more racial/ethnic discrimination drink more than Asian

Americans who experience less unfair treatment and perceive less racial/ethnic

discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that

Asian Americans who experience more family conflict drink more than Asian Americans

who experience less family conflict.

4. Are there relationships among degree of acculturation, acculturative stress (unfair

treatment, perceived racial/ethnic discrimination and family conflict), and alcohol use?

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair

treatment and perceived racial/ethnic discrimination. It is hypothesized that Asian

Americans who are less acculturated drink more because they experience more unfair

treatment and perceive more racial/ethnic discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family

conflict. It is hypothesized that Asian Americans who are less acculturated drink more

because they experience more family conflict.

5. Does social support from friends and family moderate the relationship between

acculturative stress (specifically, unfair treatment, perceived racial/ethnic discrimination,

and family conflict) and alcohol use?

Social support is expected to exert both an indirect and direct effect on alcohol use.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to

lower alcohol use.

Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair

treatment and perceived racial/ethnic discrimination on alcohol use. It is hypothesized

that Asian Americans who receive a greater amount of social support are better able to

cope with unfair treatment and perceived racial/ethnic discrimination and, as a result,

drink less than Asian Americans who receive less social support.

Hypothesis 5.3: Social support will also moderate the impact of family conflict on

alcohol use. It is hypothesized that Asian Americans who receive a greater amount of

social support are better able to cope with family conflict and, as a result, drink less than

Asian Americans who receive less social support.

6. Does religiosity moderate the relationship between acculturative stress (specifically,

unfair treatment, perceived racial/ethnic discrimination, and family conflict) and alcohol

use?

Religiosity is expected to both directly and indirectly impact alcohol use.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and

perceived racial/ethnic discrimination on alcohol use. It is hypothesized that Asian

Americans with a higher level of religiosity are better able to cope with unfair treatment

and perceived racial/ethnic discrimination and, as a result, drink less than Asian

Americans with weaker religiosity.

Hypothesis 6.3: Religiosity moderates the impact of family conflict on alcohol use. It is

hypothesized that Asian Americans with stronger religiosity are better able to cope with

family conflict and, as a result, drink less than Asian Americans with weaker religiosity.

7. Is acculturation related to unfair treatment, perceived racial/ethnic discrimination, and

family conflict, respectively?

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that

Asian Americans who are less acculturated experience more unfair treatment and

perceive more racial/ethnic discrimination than Asian Americans who are less

acculturated.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized

that Asian Americans who are less acculturated experience more family conflict than

Asian Americans who are more acculturated.

Figure 2 presents the expected pathways among variables.

Figure 2. Diagram of expected pathways among predictors of alcohol use for Asian Americans

Data Source and Sample

This study used Asian population data from the National Latino and Asian American

Study (NLAAS). NLAAS is part of the Collaborative Psychiatric Epidemiology Study (CPES),

which was designed to provide psychiatric epidemiological information on different U.S. ethnic

populations (Alegria et al., 2004). It is the first national study to use probability sampling and

translation services to obtain comprehensive mental health data, including substance use

disorders, among Asian Americans. Previous national surveys of Asian American were primarily

conducted in English, excluding a significant number of Asian Americans who lack English-

language skills from these studies (Nemoto, Huang, & Aoki, 1998) and thus biasing the sample;

however, NLAAS conducted interviews in each respondent’s preferred language eliminating

these potential biases. In addition, most epidemiological studies have been conducted in

locations where there is a sparse population of Asian Americans, and as such the data could not

be used to accurately estimate Asian Americans’ health behaviors (Nemoto et al., 1998). Instead,

NLAAS used high-density sampling supplemental strategies. Consequently, NLAAS increased

the likelihood that the sample and the content of the interviews were of improved quality and

equivalent to standard epidemiological studies (Alegria et al., 2006).

The NLAAS collected information between May 2002 and December 2003 from a

nationally representative sample of noninstitutionalized Asian Americans who were 18 years of

age or older and resided in any of the 50 states or Washington D.C. (Pennell et al., 2004). There

were a total of 2,095 Asian-American respondents. Target groups were Chinese, Filipinos,

Vietnamese, and persons with “other” Asian ancestry. Asian ethnic groups such as Korean,

Cambodian, and Indian were included in the “other Asian ancestry” category because sample

sizes for these ethnic groups were too small to conduct a detailed analysis on each of them

individually (Takeuchi, Hong, Gile, & Alegria, 2007). This study chose to analyze data on

Chinese, Filipino, and Vietnamese Americans but not the category of other Asian. This category

was excluded in consideration of the heterogeneity of Asian-American subgroups, as an analysis

of the other Asian category would mask differences within subgroups. This current study was

designed to take this diversity into account.

Method of sampling. NLAAS used three sampling strategies to recruit participants.

First, the core sample was recruited through multistage stratified probability sampling. Primary

sampling units (PSUs) were metropolitan statistical areas (MSAs) or county units; secondary

sampling units (SSUs) were census block groups. Once PSUs were selected, SSUs were

sampled. From the block group, households were sampled according to probability proportionate

to size (PPS) (Takeuchi, Hong, Gile, et al., 2007). Second, a high-density supplemental sampling

strategy was utilized to oversample Asian Americans in census block groups where target groups

made up more than 5% of the total households. Third, NLAAS used second-respondent sampling

to increase sample size by recruiting second respondents from households in which one

participant had already been interviewed (Takeuchi, Hong, Gile, et al., 2007).

Study Procedure

The NLAAS interviewers were selected by an independent agent and were matched by

ethnicity to the respondents. Interviewers had to be bilingual and undergo extensive interviewer

training. Respondents were contacted initially by an introductory letter and study brochure,

followed by screening either over the phone or in person. For those eligible and willing to

participate, they then participated in a full interview. Respondents chose their preferred language

for the interview, whether Chinese, Tagalog, Vietnamese, or English. Interviewers used laptop

and computer-assisted interviewing software to guide and record the interview. In the core and

high-density samples, interviews were conducted face-to-face, unless a respondent specifically

requested a telephone interview, while second respondents were interviewed via telephone. The

mean interview time was 2.6 hours. Respondents were initially compensated $50.00 for

participating in interviews, but later the compensation was increased to $150.00 to reduce

nonresponse rates.

Measures

Acculturation. Acculturation was assessed using two independent indicators: English

proficiency and generational status. English-language proficiency was assessed using three

items: "How well do you speak English"; "How well do you write English"; and "How well do

you read English." For each item, responses were given on a 4-point, Likert-type scale: (1) Poor,

(2) Fair, (3) Good, and (4) Excellent. Scores for each of these three items were summed to create

an English proficiency scale ranging from 0 to 12. Higher scores indicated higher English

proficiency. Cronbach’s Coefficient alphas for Chinese, Filipino, and Vietnamese Americans

were 0.97, 0.91, and 0.97, respectively.

Generational status was determined from two general items obtaining information

regarding: (1) whether a participant’s parents were born in the U.S. and (2) whether a participant

was born in the U.S. Based on Takeuchi, Zane, Hong, et al.’s (2007) definition, the following

categories of generational status were created: (1) “First generation” (respondents were not born

in the U.S. and had both parents not born in the U.S.), (2) “Second generation” (respondents

were born in the U.S and had at least one parent born outside the U.S.), and (3) “Third

generation” (respondents were born in the U.S and both of their parents were born in the U.S).

The reference group for the analysis was the first generation.

Acculturative stress. Acculturative stress was measured by examining three constructs:

unfair treatment, perceived racial/ethnic discrimination, and family cultural conflict.

Discrimination. NLAAS measured two aspects of discrimination: unfair treatment and

perceived racial/ethnic discrimination. These two constructs differ because unfair treatment is a

measure of routine experiences of unfair treatment while perceived racial/ethnic discrimination is

a measure of the degree to which an individual perceives that they have been discriminated

against. Chae et al. (2008) conducted an analysis of these two variables and found that unfair

treatment and perceived racial/ethnic discrimination measures captured different experiences.

Thus, in the current study, these two constructs were examined separately.

Unfair treatment was measured using a set of nine items (see Appendix A for a detailed

description). Items assessed how often respondents may have experienced several possible

scenarios, such as “You received poorer service than other people at restaurants or stores” or

“You are treated with less respect than other people.” Respondents used a 5-point response scale

to rate the frequency of discriminatory experiences, ranging from 0 (Never) to 5 (Almost every

day). Responses to the nine items were summed to create a score ranging from 0 to 45, with

higher scores indicating greater incidences of unfair treatment. Cronbach’s Coefficient alphas for

Chinese, Filipino, and Vietnamese Americans were 0.88, 0.91, and 0.92 respectively.

Perceived racial/ethnic discrimination was determined by creating a scale from three

specific items (see Appendix B for a detailed description). Respondents were asked to rate how

often: (1) other people dislike them because of their race/ethnicity; (2) people treat them unfairly

because of their race/ethnicity; or (3) they have seen friends treated unfairly because of their

race/ethnicity. Responses to the three items ranged from 0 (Never) to 3 (Often), and scores from

each item were summed to make a total score. The total score ranged from 0 to 9, with higher

scores indicating greater incidences of perceived racial/ethnic discrimination. Cronbach’s

Coefficient alphas for Chinese, Filipino, and Vietnamese Americans were 0.84, 0.84, and 0.90

respectively.

Family cultural conflict. The Family Cultural Conflict scale was a self-report, 5-item

instrument that assessed issues of cultural and intergenerational conflict between the respondents

and their families (see Appendix C for a detailed description). The five items were drawn from a

subscale of the Hispanic Stress Inventory (HIS, Cervantes, Padilla, & de Synder, 1991) and used

a 5-point response format ranging from 1 (Almost never) to 5 (Almost always). Each of the five

items was summed to create a total score, and higher scores indicated greater family conflict.

The Cronbach's Coefficient alphas for Chinese, Filipino, and Vietnamese Americans were 0.74,

0.76, and 0.80 respectively.

Social support. The NLAAS study assessed two facets of social support: (1) family and

(2) friends. In the current study, these two constructs were used separately. Family support was

measured using the question, "How much can you open up to relatives who do not live with you

if you need to talk about your worries?" Friend support was measured using the question, “How

much can you open up to your friends who do not live with you if you need to talk about your

worries?” In NLAAS, four responses were given to these questions: (1) not at all, (2) little, (3)

some; and (4) a lot. For the present study, categories of “no” versus “yes” were created to

indicate presence or absence of social support: “no” included the response not at all (coded as 0)

and “yes” including all remaining responses, ranging from little to a lot (coded as 1). The

reference group was those who did not receive support.

Religiosity. Religiosity was determined by the self reported frequency of attendance of

religious services. Respondents were asked how often they attended religious services; responses

ranged from 1 (More than once a week) to 5 (Never). For the current study, these five categories

were combined into three categories: (1) never, (2) one to three times a month, and (3) once or

more a month. The reference group was those who never attended religious services.

Alcohol use. The NLAAS had two questions that assessed alcohol consumption: (1)

frequency of alcohol use and (2) quantity of alcohol use. Frequency of alcohol use was measured

by asking “In the past 12 months, how often did you usually have at least one drink?” Responses

to this question were coded into 6 categories: (1) nearly every day, (2) three to four days a week,

(3) one to two days a week, (4) one to three days a month, (5) less than once a month, or (6) do

not drink. Quantity of alcohol use was measured by asking in an open-ended format “On the

days you drank in the past 12 months, about how many drinks did you usually have per day?”

Dawson et al. (1996) defined an abstainer as someone who had less than 12 drinks or

never drank in the previous year. Having five or more drinks per occasion was considered

hazardous drinking because consuming five or more drinks on any one occasion is associated

with an increased risk of alcohol-related problems (Archer, Grant, & Dawson, 1995). Moderate

drinking was defined as occasions during which fewer than five or more drinks were consumed

(Archer et al., 1995). Based on these definitions, this current study developed an alcohol-use

variable that consisted of the following three categories;

1). Abstaining: drank less than once a year or not at all.

2). Light-to-moderate drinking: drank less than once a month but at least once a month;

or drank one to three times a month but never has five or more drinks per occasion, or

drank once a week or more often but never drank five or more drinks per occasion.

3). Risky drinking: drank one to three times a month and had five or more drinks per

occasion; or drank once a week or more often and had five or more drinks per occasion.

Demographic variables. Demographic variables included ethnicity, gender, age, marital

status, household income, educational attainment, and religion. Participants reported their

ethnicity by responding to the question, “Which group best describes your race?” The NLAAS

offered four categories: Chinese, Filipino, Vietnamese, and other Asian. Gender was coded into

two categories: male (coded as 1) and female (coded as 0). Age was assessed by asking

respondents “How old are you?” For marital status, respondents were given five response

options: (1) married, (2) separated, (3) divorced, (4) widowed, and (5) never married; for

regression analysis, marital status was coded into a dummy variable; married (coded as 0) and

non-married (coded as 1), which included separated, divorced, widowed, and never married.

Education was measured by asking respondents to indicate the highest level of education

they had completed. Categories ranged from 1 (completed first grade) to 17 (some graduate

school education). Respondents with a high school or equivalent diploma were coded as 12.

Overall, higher numbers indicated higher education. Income was measured as a continuous

variable. Participants were also asked about religious preferences. In the NLAAS, 14 response

options were provided, and this current study recoded these options into four different categories

using the NLAAS’s guidelines. Protestantism included Protestantism with no denomination,

Baptist, Lutheran, Methodist, Presbyterian, other Protestant, and Pentecostal. Catholicism

included Catholicism with no denomination and Roman Catholic. No religion included being

agnostic/atheists, reporting no religious preference and no religion. Those reporting other

religions were identified in the category “other religion.” For the purposes of analysis and

subsequent interpretation, each of the categories of religion was transformed into a dummy

variable. The reference group for the analysis was no religion.

Analytic Plan

In order to examine the hypotheses proposed in this study, data analysis was conducted in

four phases. First, descriptive statistics of the sample and variables were generated. Bivariate

analyses were performed to test for significant differences on all variables in this study among

the three ethnic groups. Research question one was answered by using bivariate tests to find

significant differences in alcohol use across the three ethnic groups. For categorical variables, a

chi-square test was used to assess the relationship between two variables. ANOVA was

conducted to test the relationship between continuous variables and categorical variables, and

Bonferroni corrected post-hoc tests were calculated to allow for inter-group comparisons.

Second, Pearson correlation analyses were conducted to evaluate the strength of the

relationship between variables in order to address a potential problem of multicollinearity. All

categorical variables (gender, marital status, religion, family support, and friend support) were

dummy coded and entered into the correlation analysis. All scales (English-language proficiency,

unfair treatment, perceived racial/ethnic discrimination, and family conflict) and income were

considered continuous variables. Ordinal variables (education, generational status, and

religiosity) were included in the analyses as continuous measures.

Third, to test hypotheses, multivariate analyses were performed with ordinal logistic

regression or ordinary least squares (OLS) regression, depending upon the level of measurement

of the endogenous variable (see Appendix D). With respect to hypotheses two through six, the

endogenous variable was alcohol use, which was an ordinal variable. Therefore, an ordinal

logistic regression was performed. To test hypothesis seven, which pertained to the relationship

between acculturation and acculturative stressors, OLS was used because the endogenous

variables (unfair treatment, perceived racial/ethnic discrimination, and family conflict) were

continuous variables.

Ordinal logistic regression was used to analyze the endogenous variable, alcohol use,

with three ordered levels; abstaining (coded 1), light-to-moderate drinking (coded 2), and risky

drinking (coded 3). According to the parallel regression assumption (otherwise known as the

proportional odds assumption), in ordinal logistic regression, the coefficient of the linear

predictor is the same for each category of the ordinal endogenous variable. The only change is a

choice of ‘cut-points,’ and the constant in the model is the cut-point used to distinguish the two

probabilities that are comprised of odds for the endogenous variable of the regression model.

When there are m levels of the endogenous variable, there are m-1 cut-points (Long & Freese,

2006). In this study, there were two cut-points at which the endogenous variable was

dichotomized for the purpose of formulating a logistic equation. Cut-point one was found

between the probability of abstaining and the probability of a combination of light-to-moderate

and risky drinking. Cut-point two was found between the probability of a combination of

abstaining and light-to-moderate drinking and the probability of risky drinking. Whether using

cut-point one or cut-point two, it was assumed that the values of the odd ratios remains the same

(Long & Freese, 2006).

To combine two different types of regression (OLS and logistic regression) in the same

path model, there has to be a comparable method to obtain goodness-of-fit in the both types of

regression models. This current study used pseudo R2 and R2 for comparable path coefficients.

The reasoning proceeds as follows. Proportional reduction of deviance in logistic regression is

comparable to R2 in OLS regression. Deviance is equal to the sum of squared errors. Deviance is

measured by -2 times natural log likelihood of the model. Therefore, R2 is equal to 1- deviance.

Because logistic regression generates pseudo-R2, OLS R2 and, logistic R2 can be compared.

Consequently, there is comparable goodness-of-fit measure in both types of regression models.

A proportional reduction of error due to a particular variable in a logistic regression

yields a path coefficient comparable to that of the R2 change due to a variable in an OLS

regression. Reduction of the deviance in a logistic regression is measured by a proportion that

indicates the decrease in total error. In that proportion, the denominator represents the amount of

error (deviance) prior to the addition of the new variable to the model. The numerator in the

proportion is equal to the error (deviance) after the introduction of the new variable. Therefore,

the proportion represents the reduction of deviance is due to introduction of the new variable.

This proportional reduction of deviance is the same as a partial pseudo-R2 . The path coefficients

in the both types of regression are comparable and can be used to integrate these two types of

path coefficients into a unified path model.

Lastly, a diagram was created to illustrate the different, both the relationships between

the predictors of alcohol use and their relationship directly to alcohol use. As mentioned above,

because of each of the types of regression use different metrics for their respective coefficients,

each were transformed to a comparable metric. The path coefficients of logistic and OLS

regression were calculated respectively in changes of pseudo-R2 and change of R2. In order to

calculate R2 change, after all other covariates are placed in the model, an initial R2 was computed.

Then, the variable being examined was added, and the second R2 was computed. The difference

between the two R2 was an R2 change (ΔR2) was caused by the addition of the variable under

consideration. Therefore, the path coefficient represented the effect of this variable in the model.

The direction of the path of a variable was determined by the sign of the regression coefficients.

The significance of the coefficient was determined by the p-value of variable in the model. A

significant level was determined at the usual p-value of .05. In regards to calculation of an

indirect effect to test hypothesis five, two significant direct path coefficients were multiplied.

Each hypothesis was tested separately. Because of the level of measurement of a variable

in the model could be either continuous or ordinal, the necessity for different types of regression

models precluded simultaneous estimation of all coefficients in one model. Therefore, the path

coefficients of a model were estimated sequentially. In addition, this procedure was followed for

Chinese, Filipino, and Vietnamese Americans separately.

Sample size for the current study is consistent with the generally accepted practice N ≥ 50

+8 m (where m is the number of independent variables) (Tabachnick & Fidell, 2007). Since there

were 30 independent variables including interaction variables, a minimum of 290 cases were

needed to appropriately use regression analysis. The sample size for Chinese, Filipino, and

Vietnamese Americans were 600, 508, and 520 respectively. Therefore, the sample size for this

study was considered sufficient for data analyses.

The statistical software used to analyze the study data was Stata 10 (StataCorp, 2007).

Stata 10 is capable of analyzing complex survey data. In this case, the complex sample included

the sampling weight, a clustering as well as stratification variable. Subpopulation syntax was

used to isolate subgroups for separate analysis. In addition, standard errors of estimates were

produced in Stata 10 using Taylor linearization, a method of robust variance estimation with the

sample weights that corrects for heteroskedasticity as the sample size becomes large (White,

1980). A level of statistical significance of p < .05 was applied for all tests.

Ethical Issues

The original study was conducted by multiple investigators from different institutions;

the NLAAS required approvals from each Institutional Review Board (IRB). The IRB

Committees of Cambridge Health Alliance, the Harvard School of Public Health, the University

of Washington, and the University of Michigan approved all recruitment, consent, and

interviewing procedures (Center for Multicultural Mental Health Research, 2009). All study

procedures, as well as a written consent form, were translated and explained in each respondent’s

preferred language, consistent with recommended ethical procedures.

As noted earlier, this study used a subset of data from the NLAAS. Because this study

involved secondary analysis of a pre-existing, de-identified, and publicly available dataset, no

participants were recruited for this current study and there was no potential for harm to

participants. Research involving the study of existing publicly available de-identified data is one

of categories of human subjects’ research exempt from continuing review under federal

regulations. This current study design was submitted to University Committee on Activities

Involving Human Subjects (UCAIHS) at New York University, with a request for exempt status

based on conducting a secondary analysis. The Exempt Certification Form-Category was

approved on January 21, 2010 (see Appendix E for detailed description).

Chapter VI

Results

This chapter presents the results of the data analyses. First, descriptive statistics of the

sample as a whole are presented. Second, descriptive statistics of all variables are broken down

and presented by Asian subgroup for Chinese, Filipino, and Vietnamese Americans. Also, results

of bivariate analyses are presented to compare the subgroups on all variables. Third, after a brief

discussion of the problem of multicollinearity, the results of ordinal logistic regression and OLS

regression and the final path diagram illustrating relationships between variables are presented

for each ethnic subgroup. The diagram for each subgroup shows paths between variables based

on testing hypothesized relationships one at a time, rather than simultaneously.

Characteristics of the Sample

Table 2 summarizes sample and population sizes of Chinese, Filipino, and Vietnamese

Americans. Chinese Americans were the largest of the three populations.

Table 2: Weighted and unweighted sample subgroups sizes

Sample/Population Size

Chinese Americans

Filipino Americans

Vietnamese Americans

Unweighted N 600 508 520 Weighted N 2,234,825 1,681,420 1,007,086

Table 3 describes socio-demographic characteristics of the sample of Chinese, Filipino,

and Vietnamese Americans in unweighted sample size (see Appendix F for details in weighted

sample size). No statistical differences among the three groups were found for age, gender,

marital status, or family cultural conflict. The mean age for the three groups combined were

approximately 42 years old. Slightly more than half of the entire sample was female (52.5%) and

approximately two thirds were currently married. The mean family conflict score across the three

groups was approximately 6 and ranged from 5 to 15.

Significant differences were found between subgroups for education, income, English-

language proficiency, generation, unfair treatment, perceived racial/ethnic discrimination, family

and friend support, and religiosity. A chi-square analysis found a significant difference in

education among three groups (χ2 = 9.41, df = 6, p < .001). Overall, Vietnamese Americans were

the least educated, as they had the highest proportion of respondents (31.7%) with the lowest

level of education. In contrast, Chinese Americans were the most well educated, as they had the

largest proportion of respondents (45.6%) reporting some graduate education.

Filipino Americans reported the highest mean income, while Vietnamese Americans

were the most impoverished group with the lowest mean income. The most common religion

among Filipinos was Catholicism, and this is consistent with their cultural and historical

background. The majority of Chinese Americans (49.4%) and Vietnamese Americans (54.7%)

reported having no religion or “other religion,” respectively.

Of the three groups, Filipino Americans were the most proficient in English, as reflected

in the highest mean score of English language proficiency. Given their historical background and

the U.S. occupation of the Philippines, this is not surprising, even among first generation

Filipinos. All three groups were overwhelmingly comprised of first generation respondents, with

Vietnamese Americans having a significantly larger proportion than the other two groups at

97.8%.

From the self report measures, Filipino Americans reported the highest level of unfair

treatment whereas Chinese Americans reported the greatest level of perceived racial/ethnic

discrimination. Self-reported family and friend support were highest among Filipino Americans

and lowest among Vietnamese Americans. Filipino Americans reported attending religious

services more often than Vietnamese or Chinese Americans.

Alcohol use. Descriptive statistics (Table 3) were generated to answer the first research

question "What drinking patterns are found among subgroups of Asian Americans?" The

relationship between alcohol use and ethnicity was statistically significant (χ2 = 72.92, df = 4, p

< .001). Vietnamese Americans (71.9%) had the largest proportion of abstainers from alcohol.

Filipino Americans reported the highest rates of light to moderate drinking (49.8%) and risky

drinking (5.6%). The levels of risky drinking reported among Chinese (3.0%) and Vietnamese

(1.4%) respondents were relatively low in comparison with other ethnic groups. The number of

risky drinkers in the three groups was small in unweighted sample size. When this number was

weighted for total population, the number of risky drinkers was considerably large enough to pay

attention. The number of risky drinkers in total population for Chinese and Filipino were 67,147

and 93,901. The total number of risky drinkers for Vietnamese Americans and 136, 668.

In the 2007 SAMHSA study, 8.3% of Whites, 6.1% of Hispanics, 4.7% of African

Americans, and 12.1% of Native Americans reported risky drinking patterns. However, these

subgroup rates are high when compared to the Asian population as an aggregate group who, in

the same study, had a rate of only 2.7% of risky drinkers.

Table 3. Characteristics of Chinese, Filipino, and Vietnamese Americans

Chinese Filipino Vietnamese sig. test

n (%)/mean n (%)/mean n (%)/mean

Agea n.s.

Mean 41.6 41.9 43.0

SD 14.02 16.1 14.73

Range 18-85 18-89 18-95

Genderb n.s.

Female 316 (52.5) 273 (52.5) 277 (52.5)

Male 284 (47.5) 235 (47.5) 243 (47.5)

Marital statusb

Married 414 (65.9) 346 (68.2) 384 (71.7) n.s.

Divorced 61(10.1) 50 (9.7) 38 (6.9)

Never married 125 (24.0) 112 (22.1) 98 (21.4)

Educationb χ2=9.41***,

Less than high school 85 (17.4) 53 (10.9) 152 (31.7) df=6

High school graduate 96 (16.2) 97 (20.3) 116 (21.1)

College 117 (20.8) 168 (32.0) 129 (23.5)

Graduate school 302 (45.6) 190 (36.8) 123 (23.7)

Incomea F (2, 40)=20.57*

Mean 76,675.0 81612.6 53,100.5

SD 63,051.4 57466.7 51,323.6

Range 0-200,000 0-200,000 0-200,000

Median 59,999.50 72,499.00 37,499.50

Religionb χ2=111.80***,

Protestantism 134 (20.5) 84 (15.5) 25 (5.5) df=6

Catholic 45 (7.9) 358 (71.9) 177 (32.9)

Other religion 128 (22.2) 35 (6.8) 280 (54.7)

No religion 287 (49.4) 25 (5.8) 36 (6.8)

English proficiencya F (2, 40)=121.74***

Mean 7.84 10.05 6.11

SD 3.11 2.15 2.84

Range 3-12 3-12 3-12

Generationb χ2 =51.88**,

First generation 518 (88.1) 416 (83.1) 509 (97.8) df=4

Second generation 24 (4.16) 44 (8.8) 10 (2.17)

Third generation 56 (7.74) 48 (8.1) 0

Unfair treatmenta F (2, 40)=42.68***

Mean 7.09 8.97 4.19 df=2

SD 5.98 7.08 5.85

Range 0-37 0-43 0-45

Perceived racial/ethnic discriminationa F (2, 40)=15.98***

Mean 2.53 2.02 1.87 df=2

SD 2.06 2.12 2.21

Range 0-9 0-9 0-9

Family cultural conflicta n.s.

Mean 6.51 6.6 6.14

SD 1.83 1.89 1.73

Range 5-15 5-15 5-15

Family support χ2=22.10***,

Yes 506 (85.7) 439 (86.1) 389 (75.2) df=2

No 91 (14.3) 68 (13.9) 127 (24.8)

Friend support

Yes 535 (89.1) 457 (88.6) 381 (74.4) χ2=27.19***,

No 64 (10.1) 49 (11.4) 135 (25.6) df=2

Religiosityb χ2=49.87***,

Never 349 (60.5) 75 (16.8) 121 (23.6) df=4

One to three times a month 145 (18.9) 179 (34.6) 216 (44.7)

Once a week or more 100 (13.6) 248 (48.6) 181 (31.6)

Alcohol usea χ2=72.92***,

Abstaining 369 (61.3) 232 (44.6) 380 (71.9) df=4

Light-to-moderate drinking 215 (17.8) 248 (49.8) 130 (26.7)

Risky drinking 16 (3.0) 26 (5.6) 9 (1.4) a: ANOVA test b: chi-square test df=degrees of freedom *p < .05, **p < .01, ***p < .001 n.s.: not significant

Addressing Multicollinearity

Before proceeding to the multiple regression analyses for each subgroup, bivariate

correlations among the all variables were calculated in order to assess their degree of

interrelatedness. These correlations matrices are presented in Appendix G, H, and I. Among

Chinese Americans, significant correlations ranged from 0.08 to 0.52. No variables yielded a

relationship greater than +.70; thus, these results suggested the absence of multicollinearity

(Tabachnick & Fidell, 2007).

Issues of multicollinearity were evident for the other two ethnic subgroups with reference

to the religion variable, at least in part as result of how the variable was constructed for the

research project. For the purposes of ease of interpretation, four dummy variables were created

from the categorical religion variable--Protestantism, Catholicism, No religion, Other religion—

one for each potential response. While it was necessary to check for potential association among

the dummy variables in order to avoid problems of multicollinearity, there was also the risk of

artificial conflation of the correlation coefficients because of the nature of their construction. The

dummy variables were clearly not mutually exclusive and were expected to be related. Indeed,

among Filipino Americans, the correlation between Protestantism and Catholicism was highly

negatively correlated (r = -.71, p < .001), and among Vietnamese Americans, the correlation

between Catholicism and other religion yielded r = -.78. These correlations of + .70 or higher in

the same analysis indicate a potential problem with multicollinearity (Tabachnick & Fidell,

2007). One way to solve multicollinearity is to omit one of the two highly related variables

(Tabachnick & Fidell, 2007). Given both the potential problem of multicollinearity among the

religion dummy variables and the potential for artificial conflation, this current study did not

exclude variables that were merely highly correlated with one another. The decision not to

exclude variables that were merely highly correlated with one another was made based on the

conceptualization underlying the religion dummy variable and on the need to balance the

disadvantage of multicollinearity with bias that would be introduced by omitting a variable

(Ericsson, Campos, & Tran, 1991, p.21-p.22).

Factors Related to Alcohol Use among Chinese Americans

Table 4 provides results of ordinal logistic regression related to alcohol use to assess

support for hypotheses two through six. Table 5 shows results of OLS regression related to

acculturative stressors to test hypothesis seven. The final path coefficients are presented in

Figure 3. This study found that several factors—acculturation, friend support, and religiosity—

were significantly related to alcohol use among Chinese Americans.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian Americans who are more acculturated drink more than Asian Americans who are less acculturated.

Acculturation, defined here by English-language proficiency and generational status, was

significantly related to alcohol use for Chinese Americans. Both English-language proficiency

and generational status were significantly positively associated with alcohol use after controlling

for age, gender, income, education, marital status, and religion. For a one unit increase in

English-language proficiency, the odds of an increase in drinking level was 1.12 times greater,

given all other variables constant. Generation had even more of an impact on alcohol use. Being

second generation Chinese American greatly increased the likelihood of being a light-to-

moderate or risky drinker by over five times compared to their first generation counterparts; and

being third generation Chinese American significantly increased the likelihood of increase in

alcohol use over three times that of being first generation.

Table 4. Ordinal logistic regression results for alcohol use among Chinese Americans

Variable Odds ratio P-value 95% CI

Controlling variables

Age 0.98** 0.007 0.96-0.99

Gendera 4.68*** 0.000 3.05-7.19

Income 1.00 0.122 1.00-1.00

Education 0.98 0.612 0.89-1.07

Marital statusb 1.00 0.997 0.62-1.60

Protestantismc 0.61 0.387 0.19-1.92

Catholicismc 2.24 0.063 0.95-5.26

Other religionc 1.51 0.34 0.64-3.57

Acculturation

English proficiencyd 1.12* 0.046 1.00-1.26

Second generatione 5.87** 0.018 1.37-25.07

Third generatione 3.61*** 0.000 2.04-6.37

Acculturative stressors

Unfair treatmentf 0.98 0.841 0.84-1.15

Perceived racial/ethnic discriminationg 1.37 0.085 0.96-1.96

Family conflicth 0.97 0.902 0.61-1.54

Social support/religiosity

Family supporti 6.27 0.132 0.56-70.27

Friend supporti 0.09 0.064 0.01-1.15

Religiosity-one to three time a month or lessj 4.46 0.17 0.51-38.68

Religiosity-once a week or morej 0.63 0.757 0.03-12.22

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 1.08 0.192 0.96-1.22

Unfair treatment * religiosity (once a week or more) 1.18* 0.021 1.03-1.36

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 0.87 0.528 0.57-1.34

Perceived racial/ethnic disc * religiosity (once a week or more) 1.22 0.32 0.82-1.84

Family conflict* religiosity (1 to 3 a month or less) 0.70** 0.008 0.55-0.91

Family conflict * religiosity (once a week or more) 0.86 0.366 0.62-1.20

Unfair treatment * family support 0.92 0.219 0.80-1.05

Racial/ethnic disc * family support 0.90 0.576 0.61-1.33

Family conflict * family support 0.88 0.416 0.64-1.20

Unfair treatment * friend support 1.09 0.308 0.92-1.30

Racial/ethnic disc * friend support 0.80 0.22 0.57-1.15

Family conflict * friend support 1.46 0.107 0.92-2.33 Cut1 2.00 -.47-4.48

Cut2 5.99 3.46-8.52 *p < .05, **p < .01, ***p < .001 95% CI = 95% Confidence Interval disc: discrimination a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict. i Reference group is receiving no support (Yes = 1; No = 0). j Reference group is attending no religious services.

Hypothesis 3.1: Unfair treatment and perceived racial/ethnic discrimination have a direct effect

on alcohol use. It is hypothesized that Asian Americans who experience more unfair treatment

and perceive more racial/ethnic discrimination drink more than Asian Americans who experience

less unfair treatment and perceive less racial/ethnic discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that Asian

Americans who experience more family conflict drink more than Asian Americans who

experience less family conflict.

As shown in Table 4, reported unfair treatment and perceived racial/ethnic discrimination

and family conflict were not directly related to alcohol use for Chinese Americans. Therefore,

this data did not support hypothesis 3.1 and 3.2.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and

perceived racial/ethnic discrimination. It is hypothesized that Asian Americans who are less

acculturated drink more because they experience more unfair treatment and perceive more

racial/ethnic discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is hypothesized that Asian Americans who are less acculturated drink more because they experience more family conflict.

This analysis did not support Hypotheses 4.1 and 4.2 for Chinese Americans (see Figure

3 for dotted line).

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower

alcohol use. Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment

and perceived racial/ethnic discrimination on alcohol use. It is hypothesized that Asian

Americans who receive a greater amount of social support are better able to cope with unfair

treatment and perceived racial/ethnic discrimination and, as a result, drink less than Asian

Americans who receive less social support.

Hypothesis 5.3: Social support will also moderate the impact of family conflict on alcohol use. It is hypothesized that Asian Americans who receive a greater amount of social support are better able to cope with family conflict and, as a result, drink less than Asian Americans who receive less social support.

Social support, both as a main and an interaction effect, was not related to alcohol use,

therefore this analysis did not support hypotheses 5.1, 5.2, and 5.3 for Chinese Americans.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and perceived

racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic

discrimination and, as a result, drink less than Asian Americans with weaker religiosity.

Hypothesis 6.3: Religiosity also moderates the impact of family conflict on alcohol use. It is hypothesized that Asian Americans with stronger religiosity are better able to cope with family conflict and, as a result, drink less than Asian Americans with weaker religiosity.

Religiosity as a main effect was not negatively, directly related to alcohol use, thus

hypothesis 6.1 was not supported for Chinese Americans. The interaction of religiosity and

unfair treatment was statistically significant (p < .05); however, the direction was the opposite of

that predicted by hypothesis 6.2. Those Chinese Americans who experienced unfair treatment

and attended religious service one or more times a week had a greater likelihood of being light-

to-moderate or risky drinkers as compared to those who attended no religious services. In

addition, there was no statistically significant relationship between the interaction of perceived

racial/ethnic discrimination and religiosity and alcohol use. Therefore, this analysis did not

support hypothesis 6.2.

The interaction of religiosity and family conflict was related to alcohol consumption for

Chinese Americans. With higher family conflict, Chinese Americans who attended religious

services one or more times a week were less likely to be light-to-moderate or risky drinkers than

those who attended no religious services. This study found that religiosity had a negative joint

(interaction) effect over and above the individual main effects on the relationship between family

conflict and alcohol use for Chinese Americans. When the interaction effect was modeled, the

main effect of family conflict was not significant. Thus, this analysis did not support hypothesis

6.2.

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian

Americans who are less acculturated experience more unfair treatment and perceive more

racial/ethnic discrimination than Asian Americans who are more acculturated.

Hypothesis 7.2: Acculturation has a direct effect on family conflict. It is hypothesized that Asian Americans who are less acculturated experience more family conflict than Asian Americans who are more acculturated.

As shown Table 5, English-language proficiency and generational status as indicators of

acculturation were not directly associated with unfair treatment and family conflict for Chinese

Americans. With respect to perceived racial/ethnic discrimination, first generation Chinese

Americans perceived greater discrimination than did second and third generation Chinese

Americans. In other words, Chinese Americans who were less acculturated to the mainstream

society and experienced more acculturative stress. This analysis supported hypothesis 7.1.

However, hypothesis 7.2 was not supported.

Table 5. OLS regression results for acculturative stressors among Chinese Americans Variables Acculturative stressors

Unfair treatment

Perceived Racial/ethnic discrimination

Family cultural conflict

Controlling variables Beta Beta Beta

Age -0.06** -0.02** 0.00

Gendera 1.28** 0.22 -0.16

Income 0.00* 0.00 0.00

Education 0.07 0.01 0.07*

Marital statusb 1.50* -0.08 0.70**

Protestantismc -0.21 -0.21 0.11

Catholicismc -0.03 -0.20 0.72**

Other religionc 0.48 -0.14 0.47*

Acculturation

English proficiencyd 0.22 -0.02 0.00

Second generatione 0.34 -1.65** -0.24

Third generatione -0.38 -0.68* -0.06

*p < .05, **p < .01, ***p < .001 a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict.

The overall path diagram results are presented in Figure 3. Although statistical

significance was found for some R2 estimates, the amount of variance accounted for by each

variable was typically small.

Figure 3: Final Model for Chinese Americans

B: logistic regression unstandardized coefficients. b: OLS Regression unstandardized coefficients. R2: changes of pseudo-R2 to make coefficients comparable.

Factors Related to Alcohol Use among Filipino Americans

Tables 6 and 7 present results of the ordinal logistic regression in relation to alcohol use

(hypotheses two through six) and OLS regression related to acculturative stressors (hypothesis

seven) for Filipino Americans. The final model for Filipino Americans is presented in Figure 4.

Some factors, such as English proficiency, unfair treatment, perceived racial/ethnic

discrimination, family support, and friend support were significantly associated with alcohol use,

some positively and others negatively.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian Americans who are more acculturated drink more than Asian Americans who are less acculturated.

Of the two acculturation indicators, English-language proficiency was directly and

positively related to alcohol use after controlling for age, gender, income, education, marital

status, and religion for Filipino Americans. Having higher English-language proficiency

increased the likelihood of being a light-to-moderate or risky drinker as compared to having

lower English-language proficiency. In other words, the odds of being light-to-moderate or risky

drinker were increased by 1.22 for each unit increase in the level of English-language

proficiency. Generational status was not significantly associated with alcohol use. Therefore, this

analysis partially supported hypothesis 2.1.

Table 6. Ordinal logistic regression results for alcohol use among Filipino Americans

Variable Odds ratio P-value 95% CI

Controlling variables

Age 0.96*** 0.000 0.94-0.98

Gendera 7.68*** 0.000 5.21-11.31

Income 1.00 0.534 1.00-1.00

Education 1.06 0.071 0.99-1.13

Marital statusb 1.03 0.931 0.55-1.94

Protestantismc 1.17 0.742 0.46-3.00

Catholicismc 1.20 0.706 0.45-3.23

Other religionc 1.48 0.162 0.85-2.58

Acculturation

English proficiencyd 1.22* 0.031 1.02-1.45

Second generatione 1.22 0.52 0.65-2.29

Third generatione 2.30 0.159 0.71-7.46

Acculturative stressors

Unfair treatmentf 1.09* 0.014 1.02-1.17

Perceived racial/ethnic discriminationg 0.48** 0.009 0.29-0.83

Family conflicth 1.16 0.465 0.77-1.76

Social support/religiosity

Family supporti 0.02** 0.002 0.00-0.21

Friend supporti 5.71 0.246 0.25-128.51

Religiosity-one to three time a month or lessj 4.76 0.11 0.69-32.60

Religiosity-once a week or morej 0.89 0.873 0.21-3.71

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 1.00 0.984 0.90-1.11

Unfair treatment * religiosity (once a week or more) 1.00 0.979 0.87-1.15

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 0.88 0.330 0.68-1.14

Perceived racial/ethnic disc * religiosity (once a week or more) 0.76 0.177 0.51-1.14

Family conflict* religiosity (1 to 3 a month or less) 0.75 0.075 0.54-1.03

Family conflict * religiosity (once a week or more) 0.93 0.460 0.77-1.13

Unfair treatment * family support 0.89* 0.031 0.80-0.99

Racial/ethnic disc * family support 2.12*** 0.000 1.44-3.13

Family conflict * family support 1.91*** 0.000 1.43-2.54

Unfair treatment * friend support 1.05 0.119 0.99-1.11

Racial/ethnic disc * friend support 1.10 0.642 0.73-1.66

Family conflict * friend support 0.61*** 0.024 0.40-0.93

Cut1 1.344 -2.22-4.91

Cut2 5.68 1.87-9.49 *p < .05, **p < .01, ***p < .001 95% CI = 95% Confidence Interval disc: discrimination a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict. i Reference group is receiving no support (Yes = 1; No = 0). j Reference group is attending no religious services.

Hypothesis 3.1: Unfair treatment and racial/ethnic discrimination have a direct effect on alcohol

use. It is hypothesized that Asian Americans who experience more unfair treatment and perceive

more racial/ethnic discrimination drink more than Asian Americans who experience less unfair

treatment and perceive less racial/ethnic discrimination.

Hypothesis 3.2: Family conflict has a direct effect on alcohol use. It is hypothesized that Asian Americans who experience more family conflict drink more than Asian Americans who experience less family conflict.

After controlling for age, gender, income, education, marital status, and religion, among

Filipino Americans, the odds of being a light-to-moderate or risky drinker were associated with

an increase in experiencing unfair treatment. Contrary to the hypothesis, this study found that

those with lower perceived racial/ethnic discrimination were significantly more likely to drink

than those with greater perceived racial/ethnic discrimination. Taken together, these findings

offer partial support for hypothesis 3.1. Family conflict was not significant predictor of drinking

for Filipino Americans, and hypothesis 3.2 was not supported.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and

racial/ethnic discrimination. It is hypothesized that Asian Americans who are less acculturated

drink more because they experience more unfair treatment and perceive more racial/ethnic

discrimination.

This study found that being third generation Filipino American as an indicator of

acculturation had an indirect effect on alcohol use through unfair treatment (Figure 4 for the

solid line among generational status, unfair treatment, and alcohol use). The indirect effect of the

third generation status through unfair treatment explained 0.006% of the variance of alcohol use

(see Appendix J for a detailed description). Because of estimation of the total subpopulation of

Filipino Americans, this effect was statistically significant. The product of two positive direct

effects was also a positive indirect effect. In other words, compared to first generation Filipino

Americans, third generation Filipino Americans who experienced unfair treatment tended to

increase levels of alcohol use by being light-to moderate or risky drinkers. This finding turns out

to be in the opposite direction of hypothesis 4.1. Therefore, hypothesis 4.1 was inconsistent with

this study finding for Filipino Americans.

Neither second generation status nor English-language proficiency had an indirect effect

on alcohol use through unfair treatment, racial/ethnic discrimination, or family cultural conflict

for Filipino Americans. Therefore, this analysis did not support hypotheses 4.1 or 4.2.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower

alcohol use.

Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment

and racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans who

receive a greater amount of social support are better able to cope with unfair treatment and

perceived racial/ethnic discrimination and, as a result, drink less than Asian Americans who

receive less social support.

Hypothesis 5.3: Social support will moderate the impact of family conflict on alcohol use. It is hypothesized that Asian Americans who receive a greater amount of social support are better able to cope with family conflict and, as a result, drink less than Asian Americans who receive less social support.

No consistent significant results were found for social support among Filipino Americans.

Family support as a main effect was significantly associated with alcohol use. Filipino

Americans who reported family support were less likely to be light-to-moderate or risky drinkers

compared to those who did not. Interactions of family support and unfair treatment and

racial/ethnic discrimination and family conflict were statistically significant. With respect to this

interaction effect, Filipino Americans who reported unfair treatment and reported the presence of

family support were less likely to drink than those who reported no family support.

However, family support did not function as a buffer on the relationship between

perceived racial/ethnic discrimination and drinking or between family cultural conflict and

drinking. Those who perceived racial/ethnic discrimination and received family support were

more likely to report drinking than those who received no family support. In addition, Filipino

Americans who experienced family conflict and received more family support were more likely

to be light-to-moderate or risky drinkers than abstinent.

Friend support as a main effect was not associated with drinking for Filipino Americans.

The interaction between friend support and family conflict was statistically significant. Filipino

Americans who experienced family conflict and received friend support were less likely to be

light-to-moderate or risky drinkers than those who received no friend support. The odds of

increase in alcohol use were 0.61 times lower for each one unit increase in the interaction of

friend support and family conflict. Therefore, this analysis partially supported hypotheses 5.1,

5.2, and 5.3.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and perceived

racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic

discrimination and, as a result, drink less than Asian Americans with weaker religiosity.

Hypothesis 6.3: Religiosity moderates the impact of family conflict on alcohol use. It is hypothesized that Asian Americans with stronger religiosity are better able to cope with family conflict and, as a result, drink less than Asian Americans with weaker religiosity.

Religiosity as both a main and an interactive effect was not related to alcohol use for

Filipino Americans. Therefore, this analysis did not support hypotheses 6.1, 6.2, and 6.3.

As was the case for Chinese Americans, among Filipino Americans, there were many

significant R2 estimates in the relevant path diagram (Figure 4), but the amount of variance

explained by those variables was small, indicating weak relationships within this data.

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian

Americans who are less acculturated experience more unfair treatment and perceive more

racial/ethnic discrimination than Asian Americans who are more acculturated.

Being third generation rather than first generation Filipino American was a statistically

significant factor in relation to unfair treatment (b = 3.98, p < .002) (see Table 7). Those who

were more acculturated to the dominant society reported more unfair treatment. This finding was

in the opposite direction of the proposed hypothesis. In addition, no statistically significant

differences in unfair treatment were found between the first and the second generation Filipino

Americans. Furthermore, acculturation (as indicated by English-language proficiency and

generational status) was not directly associated with perceived racial/ethnic discrimination and

family conflict. Therefore, hypotheses 7.1 and 7.2 were not supported for Filipino Americans.

Table 7. OLS regression results for acculturative stressors among Filipino Americans Variable Acculturative stressors

Unfair treatment

Perceived Racial/ethnic discrimination

Family cultural conflict

Controlling variables Beta Beta Beta

Age -0.07** 0.00 -0.02*

Gendera 2.29** 0.19 -0.36

Income 0.00 0.00 0.00

Education 0.26 0.14*** 0.04

Marital statusb 0.33 -0.07 -0.13

Protestantismc 1.90* 0.22 0.48

Catholicismc 0.32 0.06 0.02

Other religionc 1.21 -0.36 0.47

Acculturation

English proficiencyd -0.29 -0.08 -0.03

Second generatione -0.28 0.19 -0.36

Third generatione 3.98** -0.04 -0.35 *p < .05, **p < .01, ***p < .001 a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict.

Figure 4. Final Model for Filipino Americans

B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients. R2: changes of pseudo-R2 to make coefficients comparable.

Factors Related to Alcohol Use among Vietnamese Americans

Tables 8 and 9 show results of ordinal logistic regression related to alcohol use

(hypotheses two through six) and of OLS regression related to acculturative stressors (hypothesis

seven), respectively for Vietnamese Americans. Figure 5 presents the final model. Overall, fewer

factors--English proficiency, religiosity, and interaction of religiosity and unfair treatment--were

identified that related to alcohol use in this subsample than in the other two Asian American

groups studied.

Hypothesis 2.1: Acculturation has a direct effect on alcohol use. It is hypothesized that Asian Americans who are more acculturated drink more than Asian Americans who are less acculturated.

English-language proficiency as one acculturation indicator was directly and positively

related to alcohol use among Vietnamese Americans, after controlling for age, gender, income,

education, marital status, and religion (Table 8). Higher English-language proficiency was

positively associated with increased likelihood of light-to-moderate or risky drinking compared

to lower English-language proficiency. However, generational status was not significantly

associated with alcohol use for Vietnamese Americans. Hence, this analysis partially supported

hypothesis 2.1.

Table 8. Ordinal logistic regression results for alcohol use among Vietnamese Americans

Variable Odds ratio P-value 95% CI

Controlling variables

Age 1.01 0.368 0.99-1.03

Gendera 5.25*** 0.000 2.62-10.5

Income 1.00 0.491 1.00-1.00

Education 0.98 0.583 0.89-1.07

Marital statusb 0.89 0.747 0.43-1.85

Protestantismc 0.64 0.665 0.78-5.23

Catholicismc 5.33* 0.032 1.17-24.31

Other religionc 3.20* 0.030 1.13-9.08

Acculturation

English proficiencyd 1.14** 0.016 1.03-1.27

Second generatione 2.69 0.207 0.56-12.85

Third generatione

Acculturative stressors

Unfair treatmentf 1.10 0.240 0.93-1.30

Perceived racial/ethnic discriminationg 1.12 0.565 0.76-1.65

Family conflicth 0.71 0.274 0.39-1.32

Social support/religiosity

Family supporti 0.32 0.345 0.03-3.60

Friend supporti 0.84 0.895 0.06-12.03

Religiosity-one to three time a month or lessj 0.86 0.899 0.07-9.94

Religiosity-once a week or morej 0.04* 0.049 0.00-0.98

Interaction of support/religiosity

Unfair treatment * religiosity (1 to 3 a month or less) 0.93 0.382 0.79-1.10

Unfair treatment * religiosity (once a week or more) 0.82* 0.040 0.68-0.99

Perceived racial/ethnic disc* religiosity (1 to 3 a month or less) 1.04 0.864 0.69-1.56

Perceived racial/ethnic disc * religiosity (once a week or more) 0.89 0.533 0.60-1.30

Family conflict* religiosity (1 to 3 a month or less) 0.94 0.776 0.60-1.46

Family conflict * religiosity (once a week or more) 1.55 0.089 0.93-2.57

Unfair treatment * family support 0.96 0.660 0.79-1.16

Racial/ethnic disc * family support 1.04 0.857 0.68-1.58

Family conflict * family support 1.24 0.263 0.84-1.81

Unfair treatment * friend support 1.11 0.245 0.93-1.32

Racial/ethnic disc * friend support 1.03 0.884 0.65-1.64

Family conflict * friend support 1.11 0.665 0.68-1.80

Cut1 2.89 -1.22-7.00

Cut2 7.04 2.87-11.20 *p < .05, **p < .01, *** p< .001 95% CI = 95% Confidence Interval disc: discrimination a Reference group is female (Male = 1; Female= 0). b Reference group is being married (Married = 0; Not married = 1). c Reference group is no religion. d Higher numbers indicate greater English-language proficiency. e Reference group is first generation immigrants. f Higher numbers are associated with more unfair treatment. g Higher numbers are associated with more perceived racial/ethnic discrimination. h Higher numbers are associated with greater family conflict. i Reference group is receiving no support (Yes = 1; No = 0). j Reference group is attending no religious services.

Hypothesis 3.1: Unfair treatment and perceived racial/ethnic discrimination have a direct effect

on alcohol use. It is hypothesized that Asian Americans who experience more unfair treatment

and perceive racial/ethnic discrimination drink more than Asian Americans who experience less

unfair treatment and perceive less racial/ethnic discrimination.

As shown Table 8, after controlling for age, gender, income, education, marital status,

and religion, the variables of unfair treatment, perceived racial/ethnic discrimination and family

conflict were not significantly associated with alcohol use. Therefore, this analysis did not

support hypotheses 3.1 and 3.2 for Vietnamese Americans.

Hypothesis 4.1: Acculturation has an indirect effect on alcohol use through unfair treatment and

racial/ethnic discrimination. It is hypothesized that Asian Americans who are less acculturated

drink more because they experience more unfair treatment and perceive more racial/ethnic

discrimination.

Hypothesis 4.2: Acculturation has an indirect effect on alcohol use through family conflict. It is

hypothesized that Asian Americans who are less acculturated drink more because they

experience more family conflict. Acculturation did not have an indirect effect on alcohol use through unfair treatment and

perceived racial/ethnic discrimination or through family conflict for Vietnamese Americans (see

Figure 5 for dotted line). Thus, hypotheses 4.1 and 4.2 were not supported.

Hypothesis 5.1: Higher levels of social support are predicted to be directly related to lower

alcohol use.

Hypothesis 5.2: Social support is expected to moderate the negative impact of unfair treatment

and racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans who

receive a greater amount of social support are better able to cope with unfair treatment and

perceived racial/ethnic discrimination and, as a result, drink less than Asian Americans who

receive less social support.

The results showed that family and friend support as both main and interactive effects

were not associated with alcohol use for Vietnamese Americans (Table 8). Therefore this

analysis did not support hypotheses 5.1 through 5.3.

Hypothesis 6.1: Stronger religiosity is predicted to be directly related to lower alcohol use.

Hypothesis 6.2: Religiosity is expected to moderate the impact of unfair treatment and

racial/ethnic discrimination on alcohol use. It is hypothesized that Asian Americans with a higher

level of religiosity are better able to cope with unfair treatment and perceived racial/ethnic

discrimination and, as a result, drink less than Asian Americans with weaker religiosity.

As shown in Table 8, attending religious services was associated with decreased levels of

alcohol use for Vietnamese Americans, supporting hypothesis 6.1.

The interaction of religiosity and unfair treatment was statistically significant. Attending

religious services was associated with decreased drinking when Vietnamese Americans

experienced unfair treatment. When the interaction was specified, the main effect of unfair

treatment was not significant. Therefore, this analysis did not support hypothesis 6.2. The

interaction of religiosity and perceived racial/ethnic discrimination and interaction of religiosity

and family conflict were not statistically significant in relation to alcohol use. Therefore, this

analysis did not support hypothesis 6.3.

Hypothesis 7.1: Acculturation has a direct effect on discrimination. It is hypothesized that Asian

Americans who are less acculturated experience more unfair treatment and perceive more

racial/ethnic discrimination than Asian Americans who are more acculturated.

As Table 9 shows, English-language proficiency was positively associated with unfair

treatment. Vietnamese Americans with high English-language proficiency reported more unfair

treatment. However, generational status was not directly associated with either discrimination or

family conflict for Vietnamese Americans. Therefore, this analysis partially support hypothesis

7.1 but did not support hypothesis 7.2.

Table 9. OLS regression results for acculturative stressors among Vietnamese Americans Variable Acculturative stressors

Unfair treatment

Perceived Racial/ethnic discrimination

Family cultural conflict

Controlling variables Beta Beta Beta

Age -0.03 0.00 -0.01

Gendera 1.19 -0.11 0.10

Income 0.00 0.00** 0.00

Education 0.06 0.13** 0.02

Marital statusb 2.61* 0.95*** 1.12***

Protestantismc -0.06 -0.68 0.00

Catholicismc -1.96 -0.77 -0.23

Other religionc -1.88* -1.40* -0.48

Acculturation

English proficiencyd 0.32* -0.03 0.04

Second generatione -1.55 -0.36 -0.25

Third generatione

Figure 5. Final Model for Vietnamese Americans

B: logistic regression unstandardized coefficients. b: OLS regression unstandardized coefficients. R2: changes of pseudo-R2 to make coefficients comparable

Summary of Findings for Chinese, Filipino, and Vietnamese Americans

A summary of hypotheses tests for the three groups is presented in Table 10. Different

drinking patterns were found for Chinese, Filipino, and Vietnamese Americans. English-

language proficiency was the only common predictor for alcohol use across the three subgroups.

Generational status was a predictor for Chinese and Filipino but not Vietnamese Americans. A

significant relationship between acculturative stressors and alcohol use was found only for

Filipino Americans. The effects of social support and religiosity yielded mixed findings.

Depending on the type of acculturative stressor and the specific subgroup, social support and

religiosity had positive or negative effects on alcohol consumption. Overall, these findings

underscore the need to examine variation across different groups of Asian Americans, both

because alcohol use rates differ and because factors associated with risk and protection seem to

differ as well.

Table 10. Summary of results from hypothesis testing for the three groups.

Chinese Filipino Vietnamese Hypothesis 2.1 Yes Partially Partially Hypothesis 3.1 Hypothesis 3.2

No No

Partially No

No No

Hypothesis 4.1 Hypothesis 4.2

No No

Hypothesis 5.1 Hypothesis 5.2 Hypothesis 5.3

No No No

Partially Partially Partially

No No No

Hypothesis 6.1 Hypothesis 6.2 Hypothesis 6.3

No No Yes

No No No

Yes Partially

No Hypothesis 7.1 Hypothesis 7.2

Yes No

No No

Partially No

Chapter V

Discussion

The current study had two aims: (1) to examine levels of alcohol use among Chinese,

Filipino, and Vietnamese Americans; and (2) to examine the interrelationships between socio-

cultural factors and alcohol use using acculturation and acculturative stress models. Most of the

literature on alcohol use among Asian Americans employs either an acculturation model alone or

an acculturative stress model alone. This study brought together the two models and thus was

better able to determine relevant socio-cultural factors associated with alcohol consumption. The

discussion section addresses (1) the differences in levels of alcohol use among the three ethnic

subgroups, (2) the study’s findings with respect to acculturation, acculturative stress, and stress

moderators and the study’s limitations, (3) the implications of the study’s findings for social

work practice and policy, and (4) recommendations for future research.

Alcohol Use

Differences in alcohol use for subgroups of Asian Americans were found in this study;

Filipino Americans (5.6%) reported the highest levels of risky-drinking behaviors, followed by

Chinese Americans (3.0%), and Vietnamese Americans (1.4%). This finding of variations in

alcohol use across subgroups is consistent with findings of previous studies (Price et al., 2002;

Wong et al., 2007) and reinforces the importance of considering diversity in alcohol

consumption across the Asian American population, as well as within specific ethnic subgroups.

The particularly high rate of drinking among Filipino Americans may be due to several

factors. This subgroup was the most acculturated of the three groups in terms of English-

language proficiency. Although detailed exploration of the role of English-language proficiency

was beyond the scope of the current study, overall Filipino Americans obtained the highest level

of English-language proficiency (10.07), followed by Chinese Americans (7.71) and by

Vietnamese Americans (6.62). Compared with their Chinese and Vietnamese American

counterparts, Filipino Americans have been more influenced by American culture from

colonization by the U.S., acquiring language proficiency as a result. In addition, Filipino

Americans in the current study reported higher mean income and higher education compared

with either Chinese or Vietnamese Americans. Some studies have reported higher income and

education to relate to higher levels of alcohol consumption (Adler et al., 1994; Chi et al., 1988;

Platt, Sloan, & Costanzo, 2010). A combination of these factors may account for why Filipino

Americans report drinking more than the other two groups.

The rate of risky-drinking reported by Chinese Americans was greater than that of

Vietnamese Americans but not as great as among Filipino Americans. In terms of immigration

history, Chinese Americans came to U.S. earlier than Vietnamese Americans and thus have been

more exposed to American culture. Although cultural attitudes toward drinking were not

examined in this study, Chinese Americans emphasize moderation and discourage heavy

drinking (Zane & Huh-Kim, 1998) in comparison with Filipino Americans, a factor that may

have contributed to these group differences.

In this study, lowest rates of reported alcohol consumption were found for the

Vietnamese. Inconsistent findings have been previously reported regarding alcohol consumption

rates for this population. One study reported that Vietnamese Americans had the lowest rate of

alcohol use among other Asian subgroups (Fong, 2007). Wong et al. (2007), however, found that

alcohol consumption among Vietnamese Americans was equivalent to that of the U.S. general

population. Wong et al. (2007) claimed that national surveys do not accurately reflect practices

within specific communities and that the type of alcoholic beverage needs to be queried, since

Vietnamese Americans do not classify beer or rice wine as alcohol. The NLAAS data analyzed

in this study do not capture such nuances in alcohol use and are thus likely to underestimate

alcohol use. Further, as Wong et al. (2007) noted, Vietnamese Americans who have experienced

forced migration are often unfamiliar with research and distrustful of authority figures, factors

that may further contribute to discrepancies between self-reported and actual prevalence of

alcohol use.

Acculturation

In line with other studies (Despuses & Friedman, 2007; Gong et al., 2003; Hahm et al.,

2003; Liu & Iwamoto, 2007; Yi & Daniel, 2001), the present research confirms the predictive

relevance of the acculturation model in relation to alcohol use among Asian Americans. This

study revealed that greater English proficiency, an indicator of greater acculturation, was related

to alcohol use among Chinese, Filipino, and Vietnamese Americans. Taken together, these

results suggest that greater exposure to U.S. cultural influences leads to more drinking. As

Takeuchi, Zane, Hong, et al. suggest (2007), Asian Americans with greater English proficiency

may have more opportunities to interact with people from the mainstream society and may learn

American drinking norms and behavior as a result.

Another indicator of acculturation, generational status, was found to predict increased

drinking among Chinese Americans, but not among Filipino or Vietnamese Americans. This

finding supports the acculturation model for Chinese Americans, consistent with previous studies

(Brown et al., 2005; Price et al., 2002). The second and the third generations of Chinese

Americans appear to adopt the dominant cultural attitudes and norms toward alcohol use which

become apparent in their drinking behavior. The fact that no significant relationship was found

between generational status and alcohol use for Vietnamese Americans may well be an artifact of

the sample, since the vast majority of Vietnamese Americans in the study (97.2%) were first

generation immigrants and none reported being third generation. The disproportionate

distribution of generational status across the three ethnic subgroups precludes meaningful

comparisons in regard to the relationship between generational status and alcohol consumption.

Acculturative Stress

Whereas the acculturation model emphasizes the gradual adoption of the norms and

behaviors of the dominant culture, the acculturative stress model posits that drinking behavior

may result from the need to relieve anxiety and tension related to acculturation. Some studies

suggest that Asian Americans use alcohol to mitigate acculturative stress (D’Avanzo et al., 1994;

Liu & Iwamoto, 2007; Su & Wong, 2006; Vega & Gil, 1999). The current study examined three

facets of acculturative stress: unfair treatment, perceived racial/ethnic discrimination, and family

cultural conflict, and found support for the acculturative stress model only among Filipino

Americans. These findings suggest that Chinese and Vietnamese Americans do not use alcohol

in a way that is associated with acculturative stress; however, the three acculturative stressors

assessed in this study are not the only possible sources of acculturative stress and may not tap the

most challenging experiences associated with acculturation for Chinese and Vietnamese

Americans.

The current study hypothesized that living with family members who have varying

degrees of acculturation would increase family discord and cause family members to turn to

drinking. This hypothesis was not supported. The fact that most Asian Americans in the study

sample were first generation adults may have contributed to the absence of findings. For first

generation families, dynamics may just be beginning to change compared to families with second

or third generation family members, and therefore conflicts generated by varying degrees of

acculturation among family members may not yet have emerged.

In this study, unfair treatment referred to subtle, routine experience of injustice, not to

major events affected by discrimination, such as job loss, financial strain, being harassed by the

police, or being discriminated against in housing. This measure of unfair treatment is of more

subtle discrimination; for example, respondents were asked the frequency of occurrence whether

they were threatened or harassed. Asian Americans in this current study may not recognize many

of these more subtle experiences as acts as unfair treatment. Many Asian Americans are first

generation immigrants and may attribute this unfair treatment to their own unfamiliarity with the

U.S. culture and are less likely to recognize it (Gee & Ro, 2009). Major event discrimination, of

possible relevance to drinking behavior, may not be tapped by the methodology that was used for

this current study.

Failure to find support for the acculturative stress model may also have resulted from

inadequacies of the measure of subtle discrimination. Additionally, some studies (e.g., Chae et

al., 2009) measured whether unfair treatment had been experienced but not the frequency of

unfair treatment, while the current study measured only frequency of discriminatory experience.

The frequencies of items in unfair treatment in this current study may reflect that few Asian

Americans experienced unfair treatment. It may also be that experiences of unfair treatment do

not appear to happen with frequency (Gee & Ro, 2009). Keeping in mind the above speculations

in regard to the failure to find general support for the acculturative stress model, the relationship

between acculturative stress and alcohol use is discussed below for each ethnic subgroup.

Filipino Americans. Among Filipino Americans, both unfair treatment and perceived

racial/ethnic discrimination were found to be related to alcohol use, though not consistently in

the expected direction. As was also found in the Gee et al. (2007) study, Filipino Americans who

reported more unfair treatment also reported more drinking. However, contrary to expectation,

those who perceived less racial/ethnic discrimination reported drinking more. These

contradictory findings deserve further attention, taking into account the differences between

subtle experiences of unfair treatment and perceptions of major racial/ethnic discrimination.

In this study, Filipino Americans reported higher average income and higher levels of

education than the two other groups. It is possible therefore that they may have more exposure to

the dominant culture, be educated about the notion of equality and have more opportunity to

socialize with non-Asian Americans. The upward mobility associated with income and education

may bring with it increased pressures to minimize or deny frank racial/ethnic discrimination.

Economically successful Filipino Americans in this study may frame their experiences as would

members of the dominant white culture, acknowledging unfair treatment but not framing their

experience in terms of racial/ethnic discrimination.

Fatalism may also be a factor, with Filipino Americans accepting racial discrimination as

an aspect of life that they cannot control and must therefore accept. Holding a fatalistic view,

however, may not contribute to using drinking as a coping mechanism. Such an interpretation is

consistent with the findings of Noh, Kaspar, Hou, and Rummens (1999) that Asian Americans

tended to use coping strategies of forbearance or avoidance when dealing with the uncontrollable

stressor of perceived discrimination. Noh et al. (1999) stated that when ethnic minority group

members encounter discrimination they face a no-win situation (p. 203) and, to save face, tend

not to confront, but rather avoid, the uncomfortable situation.

These conflicting results may indicate that there is indeed no association between either

unfair treatment or perceived racial/ethnic discrimination and alcohol use for Filipino Americans.

100

As Yoo, Gee, Lowthrop, and Robertson (2009) reported, different forms of racial discrimination

may have greater or less impact on alcohol use. Alternatively, the current study’s inconsistent

findings may result from the specific, and limited, ways of measuring unfair treatment and

perceived racial/ethnic discrimination incorporated in the original study.

Chinese and Vietnamese Americans. With respect to Chinese and Vietnamese

Americans, this study did not find support for the proposed hypothesis; none of the acculturative

stressors investigated were associated with drinking. One likely explanation for this finding is

that the effects of acculturative stressors may not be clearly pronounced among first generation

immigrants. The effects of discrimination accumulate over lifetimes and may not become

manifest until the second or third generation (Harrell, 2000).

The Relationship between Acculturation and Acculturative Stress

This research was based on the assumption that the acculturation process produces

acculturative stress and that those who are less acculturated would experience greater

acculturative stress. In the current study, the relationship between acculturation and acculturative

stress was significant for Chinese Americans and Filipino Americans. However, the direction of

relationship was inconsistent for Chinese Americans and Filipino Americans; therefore, only

partially supporting the assumptions mentioned.

With respect to Chinese Americans, the first generation perceived more racial/ethnic

discrimination compared to the second and third generation, in line with previous research

(Caetano et al., 2008). It is likely that, in comparison with later generations, first generation

Chinese Americans experience more tension generated by the incongruence between their own

culture and the new culture of the U.S.

101

In contrast to Chinese Americans, the present data show that second and third generation

Filipino Americans reported greater unfair treatment in comparison to their first generation

counterparts, in the line with a previous study (Gee, 2008). A possible explanation is that more

exposure to the new culture enables ethnic minorities and immigrants to discern subtle nuances

of unfair treatment. Also, first generation immigrants typically migrate to where their own ethnic

community already exists (Lai & Arguelles, 2003), whereas subsequent generations may be less

likely to remain in geographically and ethnically defined communities. Second and third

generation Filipino Americans may be less likely to live in ethnic enclaves and may therefore

have more contact with people from other ethnic backgrounds. Greater contact with ethnically

heterogeneous communities may contribute to increased awareness of the variability of treatment

experienced by members of different ethnic minorities in their daily lives. The current study fails

to demonstrate a consistent association between acculturation and acculturative stress or that

acculturation per se leads to stress.

Social Support and Religiosity

The current study explored the buffering effects of social support and religiosity and

hypothesized that the presence of social support and more frequent attendance at religious

services would moderate the relationship between acculturative stress and alcohol use. Findings

indicated that social support and religiosity both potentiated and weakened the relationship

between acculturative stressors and alcohol use. Across the three subgroups, different types of

social support emerged as significant contributors to alcohol consumption. Thus, findings

partially support the role of social support and religiosity in buffering against the negative effects

of different types of acculturative stressors for different subgroups, but each subgroup requires

individual consideration.

102

Without more specific information about drinking habits and patterns, such as with

whom respondents drank, under what circumstances, why from their perspective they drank, or

more information about the kind and extent of social support and religiosity, one can only begin

to surmise the reasons for why these different patterns of alcohol use emerged in the context of

social support/religiosity. Additionally, the heterogeneity of Asian subgroups in terms of

immigration history, religion, and culture may provide different explanations for different

subgroups. In fact, there may be seemingly contradictory explanations for the predictors and

patterns of alcohol use across subgroups. Potential explanations proposed here are generated by

considering the unique cultural contexts of each group.

It should be noted that limitations in the measurement of social support may have

contributed to inconsistent and nonsignificant findings. The indicator for social support was a

single question, which cannot capture the complexity of the social support construct.

Furthermore, the four potential responses were re-categorized into only two: received versus not-

received support. Taken together, these variable attributes constrained the ability of the measure

to detect variation in social support and limited the interpretation of the construct by the

respondent. Understanding these inconsistencies in the roles of social support and religiosity in

regards to alcohol use requires considering the context of each individual subgroup (e.g., the

specific make up of the subgroup community, their historical and cultural background, and the

values within each subgroup) and how this moderation changes across context within each

subgroup (Gee & Ro, 2009).

Chinese Americans. For Chinese Americans, only the interactions of religiosity with

unfair treatment and with family conflict were associated with alcohol use, yet in different

directions. Those who reported greater unfair treatment and attended religious services more

103

frequently were more likely to drink, whereas those who experienced family conflict and

attended religious service more frequently were less likely to drink. Religious services are a key

site of socialization among immigrants and ethnic minority groups, and it was expected that the

interactions with religious service involvement would have only yielded a negative relationship

with alcohol use. One possible explanation for these discrepant findings is that attending services

and being exposed to religious doctrine may reduce one’s negative response to family conflict,

thereby reducing motivation to drink. Religious doctrine may encourage tolerance of family

discord and working through private matters at home. When the stressor is more public, such as

unfair treatment, adherence to religious doctrine may be more difficult or stressful in the face of

injustice. This may in turn contribute to increased drinking. While religiosity appears to play an

important role in predicting alcohol use, it appears only to do so in certain contexts.

Filipino Americans. For Filipino Americans, family support was found to be the most

associated with alcohol use. Main and interaction effects were found for family support on

alcohol use, which is consistent with previous studies that have demonstrated the protective

influence family support has on alcohol consumption (Finch & Vega, 2003; Lee, Koeske, &

Sales, 2004; Yoshikawa, Wilson, Chae, & Cheng, 2004). Generally, those who received family

support drank less; and in the face of specific stressors, such as the experience of unfair

treatment, presence of family support had a buffering effect by preventing alcohol use from

increasing, as demonstrated by the interaction with unfair treatment. This buffering effect did not

remain in the presence of other stressors, such as perceived racial/ethnic discrimination or family

conflict. Those Filipino Americans who perceived racial/ethnic discrimination as well as family

conflict and received family support reported greater levels of alcohol use than those who

received no family support. It is possible that Filipino Americans share their negative

104

experiences in the family setting, which may prompt other family members to express similar

perceptions. This may increase the amount of experienced stress among the group, which may

then contribute to increased drinking. Similarly, those who experience both conflict in and

support from family (with whom they do not live) may experience pressure from the family to

maintain harmonious family relationships by sacrificing their individual needs for the sake of the

family’s needs. This may result in greater stress and more drinking. It is apparent when

comparing Chinese and Filipino Americans that type of buffer (i.e, religiosity versus family

support) has a unique impact on each in terms of their effect on alcohol use. This is a point for

future investigation.

While there was no main effect for friend support, its interaction with family conflict was

associated with alcohol use, perhaps demonstrating the importance of friend support when there

is reported discord in the family. There was no relationship between alcohol use and religiosity.

For Filipino Americans, other sources of social support did have an association with alcohol use.

Vietnamese Americans. Similar to the Chinese Americans yet different from Filipino

Americans, family and friend social support were not predictive of alcohol use among

Vietnamese Americans. Instead, religiosity was a significant independent predictor of lower

alcohol consumption, consistent with findings from previous research on this group (Yi & Daniel,

2001). In addition, there was an interaction between religiosity and experience of unfair

treatment in predicting alcohol use. Participants who experienced more unfair treatment and

attended religious services more frequently were less likely to drink that those who attended less

often. Attending religious services may help Vietnamese Americans cope with stress associated

with unfair treatment without resorting to alcohol.

Study Limitations

105

The findings of the present study should be considered in light of the strengths and

limitations of the methodology. Using the NLAAS data set offered several notable strengths. The

NLAAS data set is a large, representative national sample of non-institutionalized adults, aged

18 and older, drawn from the general population. This provided sufficient statistical power for

the current analyses. In addition, the NLAAS data set oversampled participants of Asian descent

thereby assuring an ample number of Asian American participants for this original research. The

size and scope of the NLAAS data set and the heterogeneity of Asian population sample made it

possible to conduct separate analyses for the three ethnic subgroups in the current study.

Nevertheless, the methodology of the NLAAS data set also introduced problems for these

secondary analyses. The first methodological concern about using the NLAAS data set is that

recruitment procedures required the inclusion of second respondents in the same household as

first respondents in order to increase the sample size of Asian Americans. This approach may

have introduced bias into the findings. Rather than capturing more respondents from more

households, the findings are based on more respondents who are likely to share the same

perspective. The nature and extent of bias brought about by this approach and its effects on the

generalizability of results is unknown.

Second, as is the nature of secondary analysis, the current study was limited by the

specific variables and scales used by the original study. The NLAAS data were not originally

collected for assessing alcohol-related problems but for estimating prevalence of mental illness.

Consequently, the measures of alcohol consumption were limited in number and scope. In

comparison, national studies focusing on alcohol use have included more comprehensive

questionnaires that query details of amount, frequency, and type of alcoholic beverage consumed.

Because the NLAAS assessed quantity and frequency of alcohol use and required the

106

participants to average their alcohol consumption over the entire year, this quantity-frequency

measure is not able to provide informative data for people with irregular drinking patterns

(DeFour, 1999). In addition, patterns of alcohol consumption vary culturally and therefore the

meaning of any measure of drinking has to be interpreted in a specific population with care.

As mentioned previously, another limitation of the data set is the use of single questions

to assess the complex constructs of social support and religiosity. Family and friend support was

assessed simply with questions about how openly the respondent could talk about their worries,

which may or may not have been an indicator of experienced support (i.e., someone may still

feel supported by someone with whom they may not be able to speak openly). No questions

tapped the helpfulness of social support received. Nor was there any assessment of family

support received by relatives with whom the participant lived, although family members in the

same household may provide the most immediate and crucial sources of support. Moreover, for

analysis purposes a dichotomous dummy variable (yes versus no) was created from the four

ordinal responses to social support questions. Such aggregation of responses may reduce the

variability available for analysis. These methodological limitations may be responsible for the

failure to find a significant relationship between social support/religiosity and acculturative stress

in this study. A fuller assessment of the role of social support would require multidimensional

measures and the inclusion of same-household individuals as potential sources of support.

Third, the NLAAS uses exclusively self-report measures that are subject to potentially

distorting influences such as self-presentation concerns, interviewer effects, and

misunderstanding. Most interviews were conducted face-to-face with an interviewer, which may

particularly predispose participants to minimize their negative response due to social desirability.

More importantly, cultural stigma associated with alcohol abuse is prominent in the Asian

107

American population. Hence self-reported alcohol use behavior may be inaccurate and

underestimate actual rates.

Lastly, this current study did not test all hypotheses simultaneously. As a result, causal

relationships among variables cannot be inferred from this study. In order to utilize available

variables, each of which had different levels of measurement, this study used different types of

regression analyses to assess the various relationships of interest. Despite an attempt to make the

coefficients from these different types of regression analyses comparable, the final path models

presented here are not the same as a conventional path model and should therefore not be

interpreted as such.

Implications

Social work practice. Findings from the current study suggest that a single model of

alcohol use does not fit all Asian American subgroups and underscores the importance of

understanding heterogeneity within this population. Culturally competent practice requires that

social workers continue to study patterns of alcohol use for each Asian ethnic group separately,

taking into consideration the different social, cultural, and contextual factors that may underlie

each group’s behavior. Knowing the unique protective and risk factors across Asian subgroups

may dictate different approaches to intervention in substance abuse and mental health treatment

settings.

The results of this study provide support for the role of acculturation in shaping drinking

patterns. The association of acculturation with alcohol use implies that greater cultural exposure

results in the adoption of the relevant norms, practices, and values of the dominant society in

regard to drinking. If this is the case, less acculturated individuals and recent immigrants may

have certain protective factors, such as cultural practices and family cohesion, which may

108

diminish with each successive generation of acculturation. To reduce drinking, social workers

need to assess such potentially protective resources as well as risk factors, by considering level

of acculturation and identification with the dominant society of for each individual and group

with which they work.

In the present study, English proficiency is a common factor associated with drinking

among the three Asian subgroups. Although immigrants need to learn English to adjust to

mainstream society in the United States, acquiring language facility may also increase potentially

harmful behavior in the form of increased alcohol consumption. In addition, drinking behavior

appears to differ as a function of immigrant generation. Among Chinese Americans, in particular,

generational status may be an important factor in alcohol use. Because of the high proportion of

first generation immigrants among Vietnamese Americans, more time will likely be needed to

determine how drinking patterns in this group in particular may change over time.

More generally, social workers need to understand how life experiences differ among

subsequent generations of immigrants. As acculturation increases with each generation, there

may be more opportunities and pressures for alcohol use. This calls for an emphasis on primary

prevention and health promotion: new immigrants should be educated about the potential impact

of acculturation on their children and programs need to be developed to help immigrant families

navigate acculturation across generations in culturally sensitive ways. Furthermore, other studies

suggest that prevention programs should consider the benefits of encouraging retention of

protective aspects of the culture of origin while simultaneously acculturating to the U.S., thereby

encouraging and obtaining biculturalism (Berry, 2003; Smokowski, David-Ferdon, & Stroupe,

2009). The current study provides support for the idea that biculturalism has the potential to

lower risk for increased alcohol use.

109

The current findings can be interpreted using Shannon’s (1989) model of biopsychosocial

assessment that mandates consideration of environmental, physical, behavioral, psychological,

and social factors in working with health issues of social work clients. The present data suggest

that the acculturation-related factors of English-language proficiency and generational status be

routinely included in assessments of social factors related to drinking.

The finding that Asian Americans with higher acculturation were at greater risk of

unhealthy drinking behaviors contradicts the common expectation that recent immigrants are at

greater risk because of greater adjustment, language, and economic problems. Social workers

need to identify and acknowledge the diversity of difficulties that accompany various stages of

acculturation and develop tailored approaches to prevention and treatment. For example, alcohol

awareness and education efforts aimed at Asian Americans with higher levels of acculturation

should reinforce the importance of using alcohol in moderation and emphasize adverse

consequences of excessive use. Furthermore, social workers need to pay special attention to the

needs of children of immigrants—the second or third generation—since they are at greater risk

for increased alcohol consumption.

Although this study has not supported the hypothesized model of acculturative stressors

contributing to drinking for Chinese Americans and Vietnamese Americans, social workers

would do well to examine elements of acculturative stress pertaining to Asian subgroups not

assessed within the current study. For example, Vietnamese Americans may have experienced

trauma related to the Vietnam War and may drink in order to relieve related symptoms. Thus,

social work practitioners need to understand the unique immigration histories and norms of

Asian subgroups. Based on that knowledge, social workers carefully and comprehensively need

to assess stressors relevant to specific individuals.

110

For instance, acculturation and experiences of unfair treatment are risk factors in drinking

behavior among Filipino Americans. Social workers could create a safe space for discussion of

relevant issues related to race and ethnicity and help clients develop more constructive skills for

coping with discrimination. Social workers can encourage individuals to explore how personal

characteristics and environmental contexts affect their exposure to discrimination. In addition,

they could develop workshops in the community to discuss acculturation processes and strategies

how to address barriers pertaining to discrimination and unfair treatment. Such discussions and

awareness-building activities might promote positive mental health and enhance skills for

navigating complex social environments. In addition, the present data show that Filipino

Americans drink less when they perceive more racial/ethnic discrimination, which suggests the

use of different coping skills to deal with this stressor. To explore this relationship further it is

important to assess which coping behaviors are activated in response to particular stressors, and

to explore how alternative coping strategies can be generated to manage the stress of

discrimination.

While family and friends, as well as religiosity, are important sources of support, findings

from the current study suggest that assessing and enhancing protective factors, including family

and friend support and religiosity, may require different approaches to be effective in reducing

alcohol use. Social workers need to carefully assess social support factors and the presence of

various types of stressors within the specific cultural context in which they occur. For example,

talking about family conflict in the Asian American community may bring disgrace to the family.

Since in Asian culture maintaining the integrity of family is given great value, Asian Americans

tend to keep difficulties with their family secret. Overall, studies related to social support,

religiosity, and alcohol use are scarce, and more research is needed to better understand the role

111

of social support and religiosity as potential buffers against the negative effects of stress on

alcohol use.

Social work policy. Findings from the current study suggest four implications for social

work policy. The first entails addressing the needs of the fast-growing population of Asian

Americans. Although findings indicate that Asian Americans drink less than the general U.S.

population, increased alcohol consumption can be expected as they become acculturated to the

U.S. Furthermore, although in national studies Asian Americans generally have a lower rate of

drinking than the U.S. population as a whole, a recent study reported that the highest rates of

alcohol-related motor vehicle fatalities per 100,000 population were found among Asians (19.6),

while Whites (6.2) reported the lowest rates (USDHHS, 2010a). The high accident rate for Asian

Americans suggests that adequate primary and secondary prevention programs are not in place

for this segment of the population. The overarching goal of Healthy People 2010 is to reduce

health disparities among racial and ethnic groups (USDHHS, 2010b). The lack of appropriate

prevention and intervention programs for Asian Americans may be one such disparity. Given the

expanding population of Asian Americans and the increased risk of alcohol consumption in

younger generations, accessible culturally appropriate programs are urgently needed to educate

Asian Americans about the negative consequences of alcohol use.

A more diverse social work and health care workforce is needed to ensure access to

culturally and linguistically competent services (Ro, 2009). Currently, there are few Asian

American social workers suitable to provide such a service. One study reported that of a

representative sample of NASW members (N = 1,407), 86% were white, 5% were African

Americans, while only 2% were Asian Americans (NASW, 2003). Given 4.2% of total Asian

Americans in U.S. (Reeves & Bennett, 2004), Asian Americans are relatively underrepresented

112

in the social work workforce. Recruiting bilingual and bicultural Asian individuals to enter the

field of social workers would be an important step to addressing the needs of Asian Americans

elaborated above.

Recruitment to social work, however, is only a first step. Although there are no data on

numbers of Asian American social workers who work in the addictions field, it can be inferred

from studies of social workers at large that few have practices that involve direct work in the

addictions. Of the social work sample described above, only 16 % reported addictions as a

primary, secondary, or tertiary focus of their practice (Smith, 2005). Given the projected increase

in the number of Asian Americans, Asian American social workers will be increasingly valuable

in providing addiction treatment. To address the expanding need for services, NASW and other

social work organizations should focus efforts on increasing Asian representation in social work

and encouraging social workers to integrate addiction work in their practices.

The second implication of the current research is that more national studies on alcohol or

drug use among Asian American subgroups are needed to inform policy. The current study

confirms the value of conducting separate analyses for different Asian American subgroups in

order to understand the diverse experiences of these groups. Data on Asian subgroups is required

so that interventions can appropriately address the specific problems facing these groups.

A few national studies have begun to collect data that is more targeted to specific ethnic

groups (Ghosh, 2009), but there are several notable obstacles to overcome. Many national studies

have not included Asian Americans in their data analyses because their numbers are too small for

needed statistical power (Ghosh, 2009; Lee et al., 2003). Oversampling methods may need to be

used to achieve desirable sample sizes for data analysis (Ghosh, 2009). In addition, language

translation services are needed when national studies are conducted. National studies frequently

113

provide Spanish and English options, but only a few (including the NLAAS) have provided

Asian language translation services. Because of the absence of Asian language translation, many

federal surveys are likely to miss potential respondents and severely underestimate the

magnitude of alcohol use and related problems in this important and growing population.

Third, policies aimed at increasing the welfare of immigrants have historically focused on

assimilation—integrating various ethnic populations into the “American” way of life (Thurman,

Plested, Edwards, Chen, & Swaim, 2000). The findings of the current study do not support the

value of rapidly acculturating immigrants to American culture, but rather suggest that the

retention of cultural values and norms may protect the well-being of immigrants across

increasing length of stay in the U.S. and across immigrant generations. In other words, a

bicultural model may be optimal (Berry, 1998; Oh, Koeske, & Sales, 2002). The preservation of

aspects of original culture that are protective in dealing with acculturation and acculturative

stress may be especially important.

Finally, the current study supports the importance of policies to reduce discrimination

against immigrants. Since the early 1990’s, anti-immigrant sentiments have increased in the U.S.

(Gilbert & Terrell, 2005), suggesting that immigrants bring more harmful than positive

contributions to America. Although this study provided little direct evidence for the effect of

discrimination on alcohol use, we can assume that Asian Americans who are susceptible to such

sentiments internalize negative social views and experience psychological distress. This may

increase both the development of negative ethnic identity and risk for psychological dysfunction.

Policies to reduce racial discrimination, oppression, and prejudice need to be implemented to

help prevent such negative results of immigrants.

Recommendations for Future Research

114

There are a number of directions that future research can take with regards to studies on

alcohol use among Asian Americans. First, the present findings support the importance of

attending to the heterogeneity of substance use behaviors across Asian American subgroups

(Price et al., 2002; Wong et al., 2007). Although this study took into account the heterogeneity of

Asian cultures by conducting separate analyses for three different subgroups, only a single model

was applied within each group. Future studies examining different models are needed.

Future research on alcohol use and acculturation must use more comprehensive and

multidimensional measures of acculturation. In this study, language and generational status were

used as proxy measures of acculturation, but other aspects of ethnic identity and ethnic values

need to be included. Longitudinal research would also be helpful to better understand

acculturation processes in relation to alcohol use over time. In addition, in large-scale surveys of

nonclinical populations, it would be helpful to determine the degree to which drinking patterns

reflect problems and/or cultural norms. Future studies are needed to examine Asian subgroup

cultures in depth, and to identify drinking norms within cultures, and specific variables that

increase risk of alcohol use.

Another improvement in future research would be use of more nuanced and

comprehensive measures of drinking in order to more accurately estimate and compare subgroup

drinking patterns. No information was gathered in the current study about patterns of alcohol use,

changes in alcohol use over the lifespan, attitudes about personal alcohol intake, or the types of

alcohol consumed. In addition, the current NLAAS questionnaire assessed alcohol consumption

using self-reported quantity-frequency of 12-month use. More precision of measurement across a

longer time frame would be useful.

115

This study operationalized acculturative stressors as unfair treatment and perceived

racial/ethnic discrimination and family conflict, and the results for these measures only partially

supported the existence of the predicted relationship between acculturative stressors and alcohol

use. Future studies need to measure other acculturative stressors as well, stressors such as

occupational or residential discrimination, which may affect alcohol use. In the case of

discrimination, measuring intensity and types of experiences, such as episodic stress, daily

hassles, and chronic strain is a crucial step toward understanding the impact of discrimination on

well-being. Current results may be tentative until more work is completed using more culturally

appropriate and valid constructs, and future research is needed to replicate and extend these

findings before strong and valid conclusions can be made.

Future studies will be needed to simultaneously test the effects of socio-economic status,

gender, acculturation, acculturative stress, and social resources to better understand their

dynamic interrelationships in relation to drinking behavior. Additionally, future studies are

needed to investigate other possible protective factors such as ethnic enclaves and other social

resources.

Finally, other Asian subgroups need to be included in future studies potential high-risk

groups. According to SAMHA research (2004), 62% of Japanese Americans and 52% of Korean

Americans used alcohol over the past month, compared with only 25% of Filipino, Chinese, and

Vietnamese Americans. Inclusion of Japanese and Korean Americans, who appear to be at

greater risk for alcohol use, should be a focus for future research. Ideally, these future studies

should identify points for intervention for high-risk groups.

Conclusion

116

The goal of this dissertation was to test the effects of acculturation and acculturative

stress and to examine the moderating effects of social support and religiosity on alcohol use

among three Asian American subgroups, in an attempt to take into account heterogeneity of

Asian Americans. This study provided evidence for the acculturation model of alcohol use but

only partially supported the acculturative stress model to explain alcohol consumption as a

means to cope with stress. The acculturative stressors of unfair treatment, perceived racial/ethnic

discrimination, and family conflicts were not associated with alcohol use. If there is an

association between acculturative stress and drinking behavior, it is beyond what could be

demonstrated with the methodology used in the current study.

117

REFERRENCES

Adler, N. E., Boyce, T., Chesney, M. A., Cohen, S., Folkman, S., Kahn, R. L., & Syme, S. L

(1994). Socioeconomic status and health: The challenge of the gradient. American

Psychologist, 49, 15-24.

Agarwal, D. P. (1996). Racial/ethnic and gender differences in alcohol use and misuse. In T.

Peters (Ed.), Alcohol misuse: A European perspective (pp. 23-40). London: Harwood

Academic Publishers.

Alegria, M. Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., …Shrout, P. (2004). Cultural

relevance and equivalence in the NLAAS instrument: Integrating etic and emic in the

development of cross-cultural measures for a psychiatric epidemiology and services study

of Latino. International Journal of Methods in Psychiatric Research, 13(4), 270-288.

Akutsu, P. D., Sue, S., Zane, N. W. S., & Nakamura, C. Y. (1989). Ethnic differences in alcohol

consumption among Asians and Caucasians in the United States: An investigation of

cultural and physiological factors. Journal of Studies on Alcohol, 50, 261-267.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders (4th ed). Washington, D.C: American Psychiatric Association.

Anderson, J., Moeschberger, M., Chen, M. S., Jr., Kunn, P., Wewers, M. E., & Guthrie, R.

(1993). An acculturation scale for Southeast Asians. Social Psychiatry and Psychiatic

Epidemiology, 28, 134-141.

Archer, L., Dawson, D., Grant, B. (1995). What if Americans drank less? The potential effect on

the prevalence of alcohol abuse and dependence. American Journal of Public Health,

85(1), 61-66.

118

Arliss, R. M. (2007). Cigarette smoking, binge drinking, physical activity, and diet in 123 Asian

American and Pacific Islander community college students in Brooklyn, New York.

Journal of Health Community, 32(1), 71-84.

Asian American Federation of New York (2004). Recent immigration, limited English skills and

poverty common among Korean American New Yorkers, Census analysis shows.

Retrieved November 19, 2007 from http://www.aafny.org/proom/pr/pr20040421.asp.

Au, J. G., & Donaldson, S. I. (2000). Social influences as explanations for substance use

differences among Asian-American and European-American adolescents. Journal of

Psychoactive Drugs, 32(1), 15-23.

Austin, G., Prendergast, M., & Lee, H. (1989). Substance abuse among Asian American youth.

Prevention Research Update, 5, 1-25.

Barnes, J. S., & Bennett, C. E. (2002). The Asian population: 2000. Retrieved August 12, 2009,

from http://www.census.gov/prod/2002pubs/c2kbr01-16.pdf.

Berkman, L. F., & Breslow, L. (1983). Health and ways of living: The Alameda County study.

New York: Oxford University Press.

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

International Review, 46, 5-68.

Berry, J. W. (1998). Acculturation and health: Theory and research. In S. S. Kazarian, & D. R.

Evans (Eds.), Cultural clinical psychology: Theory, research, and practice (pp. 39-57).

New York: Oxford University Press.

Berry, J. W. (2003). Conceptual approaches to acculturation. In K. M.Chun, P. B. Organista, &

G. Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research

(pp. 17-38). Washington, DC: American Psychological Association.

119

Berry, J. W. (2006). Stress perspectives on acculturation. In D. L. San & J. W. Berry (Eds.), The

Cambridge handbook of acculturation psychology (pp. 43-57). Cambridge, United

Kingdom: Cambridge University Press.

Bhattacharya, G. (1998). Drug use among Asian-Indian adolescents: Identifying protective/risk

factors. Adolescence, 33(129), 169-183.

Bhattacharya, G. (2002). Drug abuse risks for acculturating immigrant adolescents: Case study

of Asian Indians in the United States. Health and Social Work, 27(3), 175-183.

Bhattacharya, G. (2005). Social capital and HIV risks among acculturating Asian Indian men in

New York City. AIDS Education and Prevention, 17(6), 555-567.

Black, S., & Markides, K. S. (1993). Acculturation and alcohol consumption in Puerto Rican,

Cuban-American, and Mexican-American women in the United States. American Journal

of Public Health, 83, 890-893.

Braveman, P. A., Cubbin, C., Egerter, S., Chideya, S., Marchi, K. S., Metzler, M., & Posner, S.

(2005). Socio-economic status in health research: One size does not fit all. Journal of the

American Medical Association, 295, 2879-2888.

Breslow, R. A., Guenther, P. M., & Smothers, B. A. (2006). Alcohol drinking patterns and diet

quality: The 1990-2000 National Health Nutrition Examination Survey. American

Journal of Epidemiology, 163(4), 359-366.

Brook, J. S., Whiteman, M., Balka, E. B., Win, P. T., & Gursen, M. D. (1998). Drug use among

Puerto Ricans: Ethnic identity as a protective factor. Hispanic Journal of Behavioral

Science, 20, 241-254.

120

Brooks, P. J., Enoch, M. A., Goldman, D., Li, T. K., & Yokoyama, A. (2009). The alcohol

flushing responses: an unrecognized risk factor for esophageal cancer from alcohol

consumption. PLoS Medicine, 6(3), e50. doi:10.1371/journal.pmed.1000050

Brown, J. M., Council, C. L., Penne, M. A., & Gfroerer, J. C. (2005). Immigrants and Substance

Use: Findings from the 1999-2001 National Survey on Drug Use and Health. (DHHS

Publication No. SMA 04-3909, Analytic Series A-23). Rockville, MD: Substance Abuse

and Mental Health Services Administration, Office of Applied Studies. Retrieved August

19, 2008 from http://www.oas.samhsa.gov/immigrants/immigrants.pdf

Brown, S.D., Brady, T., Lent, R. W., Wolfert, J., & Hall, S. (1987). Perceived social support

among college students: Three studies of the psychometric characteristics and counseling

uses of the Social Support Inventory. Journal of Counseling Psychology, 34, 337-354.

Buki, L. P., Ma, T-C., Strom, R. D., & Strom, S. K. (2003). Chinese immigrant mothers of

adolescents: Self-perceptions of acculturation effects on parenting. Cultural Diversity and

Ethnic Minority Psychology, 9(2), 127-140.

Cabassa, L. J. (2003). Measuring acculturation: Where we are and where we need to go.

Hispanic Journal of Behavioral Sciences, 25(2), 127-146.

Caetano, R., & Clark, C. L. (2003). Acculturation alcohol consumption, smoking, and drug use

among Hispanics. In K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation:

Advance in theory, measurement, and applied research (pp. 223-240). Washington, DC:

American Psychological Association.

Caetabo, R., & Medina Mora, M. E. (1988). Acculturation and drinking pattern people of

Mexican descent in Mexico and the United States. Journal of Studies on Alcohol, 49,

462-471.

121

Caetano, R., & Mora, M. E. M. (1988). Acculturation and drinking among people of Mexican

descent in Mexico and the United States. Journal of Studies on Alcohol, 49(5), 462-471.

Caetano, R., Clark, C. L., & Tam, C. (1998). Alcohol consumption among racial/ethnic

minorities: Theory and research. Alcohol Health & Research World, 22(4), 233-239.

Caetano, R., Ramisetty-Mikler, S., Vaeth, P. A. C., & Harris. T. R. (2007). Acculturative stress,

drinking, and intimate partner violence among Hispanic couples in the U.S. Journal of

Interpersonal Violence, 22, 1431-1447.

Caetano, R., Tam, T., Greenfield, T., Cherpitel, C., & Midanik, L. (1997). DSM-IV alcohol

dependence and drinking in the U.S. population: A risk analysis. AEP, 7(8), 524-548.

Canino, G. J., Burman, A., & Caetano, R. (1992). The prevalence of alcohol abuse and/or

dependence in two Hispanic communities. In J. E. Helzer & G. Canino (Eds.),

Alcoholism in North America, Europe, and Asia (pp. 131-155). New York, NY: Oxford

University Press.

Cappell, H., & Greely, J. (1987). Alcohol and tension reduction: An update on research and

theory. In H. T. Blane, & K. E. Leonard (Eds.), Psychological theories of drinking and

alcoholism (pp. 227-271). New York: Guildford Press.

Castillo, L. G., Cano, M. A., Chen, S. W., Blucker, R., & Olds, V. (2008). Family conflict and

intragroup marginalization as predictors of acculturative stress in Latino college students.

International Journal of Stress Management, 15, 43-52.

Castillo, L. G., Conoley, C. W., Brossart, D. F., & Quiros, A. (2007). Construction and

validation of the intragroup marginalization inventory. Cultural Diversity and Ethnic

Minority Psychology, 12, 232-240.

122

Center for Disease Control and Prevention. (2006). Alcohol and public health. Retrieved April 2,

2009 from http://www.cdc.gov/alcohol.

Center for Health Workforce Studies and National Association of Social Workers (2006).

Licensed social workers in the United States, 2004: Supplement. Retrieved April 30,

2009 from http://workforce.socialworkers.org/studies/supplemental/supplement_ch2.pdf

Center for Multicultural Mental Health Research (2009). National Latino and Asian American

Study. Retrieved May 29, 2009 from http://www.multiculturalmentalhealth.org/nlaas.asp

Cervantes, R.C., Padilla, A. M., & de Snyder, N. S. (1991). The Hispanic Stress Inventory: A

culturally relevant approach to psychological assessment. Psychological Assessment, 3,

438-447.

Chae, D. H., Takeuchi, D. T., Barbeau, E. M., Bennett, G. G., Lindsey, J. C., Stoddard, A. M., &

Krieger, N. (2008). Alcohol disorders among Asian Americans: association with unfair

treatment, racial/ethnic discrimination, and ethnic identification (the National Latino and

Asian American Study, 2002-2003). Journal of Epidemiological Community Health, 62,

973-979.

Chang, D. F. (2002). Understanding the rates and distribution of mental disorders. In K. S.

Kurasaki, S. Okazaki, & S. Sue (Eds.), Asian American mental health: Assessments

theories and methods (pp. 9-27). New York: Kluwer Academic/Plenum.

Chavez, D. V., Moran, V. R., Reid, S. L., & Lopez, M. (1997). Acculturative stress in children:

A modification of the SAFE scale. Hispanic Journal of Behavioral Sciences, 19, 34-44.

Chawla, N., Neighbors, C., Lewis, M. A., Lee, C. M., & Larimer, M. E. (2007). Attitudes and

perceived approval of drinking as mediators of the relationship between the importance

of religion and alcohol use. Journal of Studies on Alcohol and Drugs, 68(3), 410-418.

123

Chen, H., Mallinckrodt, B., & Mobley, M. (2002). Attachment pattern of East Asian

international students and source of perceived social support as moderators of the impact

of U.S. racism and cultural distress. Asian Journal of Counseling, 9(1-2), 27-48.

Chen, W. W. (2003). Drug abuse prevention research for Asian and Pacific Islander Americans.

In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of drug abuse prevention: Theory,

science, and practice (pp. 411-426). New York: Kluwer Academic/Plenum.

Cheng, C. (1997). Are Asian American Employees a model minority or just a minority? Journal

of Applied Behavioral Science, 33(3), 277-290.

Chi, I., Kitano, H. H. L., & Lubben, J. E. (1988). Male Chinese drinking behavior in Los

Angeles. Journal of Studies on Alcohol, 49(1), 21-25.

Chi, I., Lubben, J. E., & Kitano, H. H. L. (1989). Differences in drinking behavior among three

Asian-American groups. Journal of Studies on Alcohol, 50(1), 15-23.

Chin, K., Lai, T., & Rouse, M. (1991). Social adjustment and alcoholism among Chinese

immigrants in New York City. Substance Use & Misuse, 25, 709-730.

Chung, Y. W. (1990-1991). Ethnicity and alcohol/drug use revisited: A framework for future

research. The International Journal of the Addictions, 25(5A & 6A), 581-605.

Chung, S. (2002). The role of generational status in alcohol consumption and alcohol-related

disorders: A study of a national sample of United Statues-born vs. foreign-born Chinese-,

Japanese-, and Korean-Americans (Doctoral dissertation). AAT 3068448

Cohen, S., & Lemay, E. P. (2007). Why would social networks be linked to affect and health

practices? Health Psychology, 26 (4), 410-417.

Cohen, S., & Pressman, S. (2004), The stress-buffering hypothesis. In N. Anderson (Ed.),

Encyclopedia of health and behavior. Thousand Oaks, CA: Sage Publications.

124

Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.

Psychological Bulletin, 98(2), 310-357.

Constantine, M. G., & Sue, D. (2006). Factors contributing to optimal human functioning in

people of color in the United States. The Counseling Psychologist, 34, 228-244.

Cross National Collaborative Group (1992). The changing rate of major depression. Journal of

the American Medical Association, 268, 3098-3105.

Culler, I., Arnod, B., & Maldonado, R. (1995). Acculturation rating scale for Mexican

Americans-II: A revision of the original ARSMA scale. Hispanic Journal of Behavioral

Health Science, 17(3), 275-304.

D’Avanzo, C. E., Frye, B., & Froman, R. (1994). Culture, stress and substance use in Cambodian

refugee women. Journal of Studies on Alcohol, 55, 420-426.

Dawson, D., Archer, L., & Grant, B. (1996). Reducing alcohol-use disorders via decreased

consumption: a comparison of population and high-risk strategies. Drug and Alcohol

Dependence, 42, 39-47.

Dawson, D., Grant, B., & Hartford, T. (1995). Variation in the association of alcohol

consumption with five DSM-IV alcohol problem domains. Alcohol Clinical Experimental

Research, 19, 6-74.

Despues, D., & Friedman, H. (2007). Ethnic differences in health behavior among college

students. Journal of Applied Social Psychology, 37(1), 131-142.

Dufour, M. C. (1999). What is moderate drinking: Defining "drinks" and drinking levels. Alcohol

Research & Health, 23(1), 5-14.

Ellison, C. G., & Levin, J. S. (1998). The religion-health connection: evidence, theory, and future

directions. Health Education and Behavior, 25(6), 700-720.

125

Ellison, C. G., Boardman, J. D., Williams, D. R., & Jackson, J. S. (2001). Religious involvement,

stress, and mental health: findings from the 1995 Detroit area study. Social Forces, 80(1),

215-249.

Epstein, J. A., Botvin, G. J., Dusenbury, L., & Diaz, T. (1997). Validation of an acculutration

measure for Hispanic adolescents. Pscyhological Reports, 79, 1075-1079.

Ericsson, N. R., Campos, J., & Tran, H. (1991). PC-Give and David Hendry's econometric

methodology. Retreived May 1, 2010 from

http://www.federalreserve.gov/pubs/ifdp/1991/406/ifdp406.pdf

Evans-Campbell, Liconclo, K. D., & Tateuchi, D. T.(2007). Race and mental health: Past

debates, new opportunities. In W. R. Avision, J.D. McLeod, & B.A. Pescosolido (Eds.)

Mental health, social mirror (pp. 169-190). New York, NY: Springer.

Farver, J. M., Xu, Y., Bhadha, B. R., & Narang, S. (2007). Ethnic identity, acculturation,

parenting beliefs, and adolescent adjustment: A comparison of Asian Indian and

European American families. Merrill-Palmer Quarterly, 53(2), 184-215.

Finch, B. K. & Vega, W. A. (2003). Acculturation stress, social support, and self-rated health

among Latinos in California. Journal of Immigrant Health, 5(3), 109-117.

Fong, T. W. & Tsuang, J. (2007). Asian-Americans, addictions, and barriers to treatment.

Psychiatry, 4(11), 51-58.

Gallagher-Thompson, D., Tazeau, Y. N., Basilio, L., Hansen, H., Polich, T. Menendez, A., &

Villa, M. L. (1997). The relationship of dimensions of acculturation to self-reported

depression in older, Mexican-American women. Journal of Clinical Neuropsychology, 3,

123-127.

126

Garcia (2005). Buscando trabajo: Social networking among immigrants from Mexico to the

United States. Hispanic Journal of Behavioral Health Sciences, 27, 3-22.

Gee, G. C., Chen, J., Spencer, M. S., See, S., Kuester, O. A., Tran, D., & Takeuchi, D. (2006).

Social support as a buffer for perceived unfair treatment among Filipino Americans;

Differences between San Francisco and Honolulu, American Journal of Public Health,

96(4), 677-684.

Gee, G. C., Delva, J., &Takeuchi, D. (2007). Relationships between self-reported unfair-

treatment and prescription medication use, illicit drug use, and alcohol dependence

among Filipino Americans. American Journal of Public Health, 97(5), 933-940.

Gee, G. C., & Ro, A. (2009). Racism and discrimination. In C. Trinh-Shevrin, N. S. Islam, & M.

J. Rey, Asian Americans communities and health: context, research, policy, and action

(pp. 364-402). San Francisco, CA: Jossey-Bass.

Ghosh, C. (2009). Asian Americans health research: Baseline data and funding. In C. Trinh-

Shevrin, N. S. Islam, & M. J. Rey, Asian Americans communities and health: context,

research, policy, and action (pp. 73-103). San Francisco, CA: Jossey-Bass.

Gilbert, M. J. (1985). Alcohol related practices, problems and norm among Mexican Americans:

An overview. In D. Spiegler, D. Tate, S. Aitken, & C. Christian (Eds.), Alcohol use

among U.S. ethnic minorities: Proceedings of a conference on the epidemiology of

alcohol use and abuse among ethnic minority group. (pp. 115-134). (National Institute on

Alcohol Abuse and Alcoholism Research Monograph No.18). Bethesda, MD: DHHS

Gilbert, M. J., & Cervantes, R. C. (1986). Patterns and practices of alcohol use among Mexican

Americans: A comprehensive review. Hispanic Journal of Behavioral Science, 8, 1-60.

127

Gilbert, N., & Terrell, P. (6th Ed.) (2005). Dimensions of social welfare policy. New York:

Pearson.

Gong, F., Takeuchi, D. T., Agbayani-Siewert, P., & Tacata, L. (2003). Acculturation,

psychological distress and alcohol use: Investigation the effects of ethnic identity ad

religiosity. In K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in

theory, measurement, and applied research (pp. 189-206). Washington, DC: American

Psychological Association.

Gordon, M. M. (1964). Assimilation in American Life: The role of race, religion, and national

origin. New York, Oxford University Press.

Goto, S. G., Gee, G. C., & Takeuchi, D. T. (2002). Strangers still? The experience of

discrimination among Chinese American Journal of Community Psychology, 30(2), 21-

224.

Gottheil, E., Druley, K. A., Pashko, S., & Weinstein, S. P. (1987). Stress and addiction. New

York: Brunner/Mazel.

Gottlieb, B. H. (1987). Using social support to protect and promote health. Journal of Primary

Prevention, 8(1-2), 49-70.

Grant, B. F., Dawson, D. A., Stinson, F. S. , Chou, S. P., Dufour M. C., & Pickering, R. P.

(2004). The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence:

United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence, 74, 223-235.

Greeley, J. & Oei, T. (1999). Alcohol and tension reduction. In K. E. Leonard, & H. T. Blane

(Eds), Psychological theories of drinking and alcoholism (2nd ed., pp. 14-53). New York:

The Guilford Press

128

Green, C. A., Freeborn, D. K., & Polen, M. R. (2001). Gender and alcohol use: the role of social

support, chronic illness, and psychological well-being. Journal of Behavioral Medicine,

24(4), 383-399.

Griffin, R., Mosher, C., Rotolo, T, & Drapela, L. (2004). An examination of drug and alcohol

use among Asian-Americans. Paper presented at the annual meeting of the American

Sociological Association, Hilton San Francisco, CA. Conference paper/unpublished

manuscript) retried from http://www.allacademic.com/meta/p109734_index.html

Hahm, H. C., Lahiff, M., & Guterman, N. B. (2003). Acculturation and parental attachment in

Asian-American adolescents’ alcohol use. Journal of Adolescent Health, 33, 119-129.

Harachi, T. W., Catalano, R. F., Kim, S., & Choi, Y. (2001). Etiology and prevention of

substance use among Asian American youth. Prevention Science, 2(1), 57-65.

Harrell, S. P. (2000). A multidimensional conception of race-related stress: Implications for the

well-being of people of color. American Journal of Orthopsychiatry, 70, 42-57.

Health Services Administration, Center for Mental Health Services. U.S. Department of Health

and Human Services (2005). Dietary Guidelines for Americans. Retrieved July 30, 2009,

from http://www.health.gov/dietaryguidelines/dga2005/document/pdf/DGA2005.pdf

Heath, D. W. (1991). Alcohol studies and anthropology. In D. J. Pitman & H. R. White (Eds.),

Society, culture, and drinking pattern reexamined (pp. 87-108). New Brunswick, NJ:

Rutgers Center of Alcohol Studies.

Helms, J. E. & Cook, D. A. (1999). Using race and culture in counseling and

psychotherapy:Theory and process. Needham Heights, MA: Allyn & Bacon.

129

Hendershot, C. S., Macpherson, L., Myers, M. G., Carr, L. G., & Wall, T. L. (2005).

Psychosocial, cultural and genetic influences on alcohol use in Asian American youth.

Journal of Studies on Alcohol, 66, 185-195.

Hirschman, C. & Shipp, C. M. (2001). The state of the American dream: race and ethnic

socioeconomic inequality in the United States, 1970-1990. In D. B. Grusky (Ed.), Social

Stratification: Class, race, and gender in sociological perspective (pp. 623-642). Boulder,

CO: Westview.

Horwistz, A. V., & Davis, L. (1994). Are emotional distress and alcohol problems differential

outcomes to stress?: An exploratory test. Social Science Quarterly, 75, 607-621.

Izuno, T., Miyakawa, M., Tsunoda, T., Parrish, K. M., Kono, H., Ogata, M., Harford, T.C., &

Towle, M. S. (1992). Alcohol-related problems encountered by Japanese, Caucasians,

and Japanese-Americans. The International Journal of the Addictions, 27(12), 1389-

1440.

Ja, D. & Aoki, B. (1993). Substance abuse treatment: Cultural barriers in the Asian-American

community. Journal of Psychoactive Drugs, 25, 61-71.

Ja, D., & Yuen, F. K. (1997). Substance abuse treatment among Asian Americans. In E. Lee

(Ed.), Working with Asian Americans: A guide for clinicians (pp. 296-308). New York:

The Guilford Press.

Jackson, J. S., Brown, T. N., Williams, D. R., Torres, M., Sellers, S., & Brown, K. (1996).

Racism and the physical and mental health status of African Americans: A thirteen year

National Panel Study. Ethnicity and Disease, 6, 132-147.

130

Jackson, P. B., & Lassiter, S. (2001). Self-esteem and race. In T. J. Owens, S. Sheldon, & N.

Goodman (Eds.), Extending self-esteem theory and research: Sociological and

psychological cultures (pp. 223-254). Cambridge, England: Cambridge University Press.

Johnson, R. C., & Nagoshi, C. R. (1990). Asian-Americans and alcohol. Journal of Psychoactive

Drugs, 22, 45-52.

Johnson, R. C., Nagoshi, C. T., Ahern, F. M., Wilson, J. R., & Yuen, S. H. L. (1987). Cultural

factors as explanations for ethnic group differences in alcohol use in Hawaii. Journal of

Psychoactive, 19(1), 67-75.

Kalodner, C. R., Delucia, J. L., &, Ursprung, A. W. (1989). An examination of the tension

reduction hypothesis: The relationship between anxiety and alcohol in college students.

Addictive Behaviors, 14, 649-654.

Kaplan, L. (2005). Addiction treatment workforce. Retrieved December 10, 2008 from

http://www.ncsl.org/programs/health/addictionib.htm

Kerr-Correa, F., Igami, T. Z., Hiroce, V., & Tucci, A. M. (2007). Pattern of alcohol use between

gender: A cross-cultural evaluation. Journal of Affective Disorders, 102(1-3), 265-275.

Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., …Kendler,

K.S. (1994). Lifetime and 12-mongth prevalence of DSM-III-R psychiatry disorders in

the United States: Results from the National Comorbidity Survey. Archives of General

Psychiatric, 51, 8-19.

Keys, K. M., & Hasin, D. S. (2008). Socio-economic status and problem alcohol use: the positive

between income and the DSM-IV alcohol abuse diagnosis. Addiction, 103(7), 1120-1130.

131

Kim, B. S. K., Atkinson, D. R., & Yang, P. H. (1999). The Asian value scales (AVS):

Development, factor analysis, validation, and reliability. Journal of Counseling

Psychology, 46, 342-352.

Kim, S., McLeod, J. H., & Shantzis, C. (1995). Cultural competence for evaluators working with

Asian-Americans communities: Some practical Considerations. In Substance Abuse and

Mental Health Services Administration (Ed.),Cultural Competence for Evaluators: A

guide for alcohol and other drug abuse prevention practitioners working with

ethnic/racial communities.(OSAP Cultural Competence Series I, DHHS. Publication No.

[SAM]95-3066, pp.203-260).Rockville, MD: SAMHSA.

Kitano, H. H. L., Iris, C., Rhee, S., Law, C. K., & Lubben, J. E. (1990). Norms and alcohol

consumption: Japanese in Japan, Hawaii and California. Journal of Studies of Alcohol,

53(1), 33-39.

Kitano, H. L., Lubben, J. E., & Chi, I. (1988). Predicting Japanese American drinking behavior.

The International Journal of the Addiction, 23(4), 417-428.

Klatsky, A. L., Siegelaub, A. B., Landay, C., & Friedman, G. D. (1983). Racial patterns of

alcoholic beverage use. Alcoholism: Clinical and Experimental Research, 7, 372-377.

Kuo, W. H. (1995). Coping with racial discrimination: The case of Asian Americans. Ethnic and

Racial Studies, 18(1), 109-127.

Kuramoto, F. H. (1997). Asian Americans. In J. Philleo & F. L. Brisbane (Eds.), Cultural

competence in substance abuse prevention. Washington, D.C.: NASW Press.

Lai, E., & Arguelles, D. (2003). The new face of Asian Pacific America: Numbers, diversity and

changes in the 21st century. Berkeley, CA: Consolidated Printers, Inc.

132

Lee, E. (1997). Overview: The assessment and treatment of Asian American families. In E. Lee

(Ed.), Working with Asian Americans: A guide for clinicians (pp. 3-36). New York: The

The Guilford Press.

Lee, E. & Mock, M. R. (2005). Chinese Families. In M. McGoldrick, J. Giordano, & N. Garcia-

Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 302-318). New York: The

Guilford Press.

Lee, M. Y., Law, P. F. M., & Eo, E. (2003). Perception of substance use problems in Asian

American communities by Chinese, Indian, Korean and Vietnamese populations. Journal

of Ethnicity in Substance Abuse, 2(3), 1-29.

Lee, R. M. (2003). Do ethnic identity and other-group orientation protect against discrimination

for Asian Americans? Journal of Counseling Psychology, 50, 133-141.

Lee, R. M. (2005). Resilience against discrimination: Ethnic identity and other-group orientation

as protective factors for Korean Americans. Journal of Counseling Psychology, 52, 36-44.

Lee, R., & Liu, H. (2001). Coping with intergenerational family conflict: Comparison of Asian

American, Hispanic, and European American college students. Journal of Counseling

Psychology, 48, 410-419.

Lee, S., Koeske, G. F., & Esther, S. (2004). Social support buffering of acculturative stress: a

study of mental health symptoms among Korean international students. International

Journal of Intercultural Relations, 28(5), 399-414.

LeMarchand, L. L., Kolonel, L. N., & Yoshizawa, C. N. (1989). Alcohol consumption pattern

among the five major ethnic groups in Hawaii: Correlations with incidence of esophageal

and oropharyngeal cancer. In National Institute on Alcohol Abuse and Alcoholism (Ed.),

133

Alcohol use among U.S. ethnic minorities (NIAAA Research Monograph 18, DHHS

Publication No. [ADM] 89-1435, pp. 355-371). Rockville, MD: NIAAA.

Lenug, P. K., & Boehnlien (2005). Vietnamese Families. In M. McGoldrick, J. Giordano, & N.

Garcia-Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 363-376). New York:

The Guilford Press.

Leu, J., Yen, I. H., Gansky, S. A., Walton, E., Adler, N. E., & Takeuchi, D. T. (2008). The

association between subjective social status and mental health among Asian immigrants:

Investigation the influence of age at immigration. Social Science & Medicine, 66(5),

1152-1164.

Lewonski, S. (1998). Elderly legal immigrants and welfare reform: An analysis of the effects of

the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The

Kansans Journal of Law Public Policy, 53, 53-67.

Liang, C., Li, L. C., & Kim, B. S. K. (2004). The Asian American Racism-Related Stress

Inventory: Development, factor analysis, reliability, and validity. Journal of Counseling

Psychology, 51(1), 103-114.

Lin, K. M., & Cheung. F. (1999) Mental health issues for Asian Americans. Psychiatric Services,

50, 774-780.

Long, J. S., & Freese, J. (2nd Ed.) (2006). Regression models for categorical dependent variables

using Stata. College Station, Texas: A Stata Press Publication.

Loue, S. (2003). Diversity issues in substance abuse treatment and research. New York, NY:

Kluwer Academic.

Louise, K. B. (2001). White paper on the health status on Asian Americans and Pacific Islanders

and recommendations for research. Nursing Outlook, 40, 173-178.

134

Lubben, J. E., Chi, I., & Kitano, H. H. (1988). Exploring Filipino American drinking behavior.

Journal of Studies on Alcohol, 49(1), 26-29.

Luczak, S. E., Elvine-Kreis, B., Shea, S. H., Carr, L. G., & Wall, T. L. (2002). Genetic risk for

Alcoholism related to level of response to alcohol in Asian American men and women.

Journal of Studies on Alcohol, 63, 74-82.

Makimoto, K. (1998). Drinking patterns and drinking problems among Asian-Americans and

Pacific Islanders. Alcohol Health & Research World, 22(4), 270-276.

Margiglia, F. F., Kulis, S., & Hecht, M. (2001). Ethnic labels and ethnic identity as predictors of

drug use among middle school students in the Southwest. Journal of Research on

Adolescence, 11, 21-48.

Marin, G. & Gamba, R. J. (2003). Acculturation and changes in cultural values. In K. M.Chun,

P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in theory, measurement, and

applied research (pp. 83-94). Washington, DC: American Psychological Association.

Matsuyoshi, J (2001). Substance abuse interventions to Japanese and Japanese American clients.

In S. L. A. Straussner (Ed.), Ethnocultural factors in substance abuse treatment (pp. 345-

392). New York: The Guilford Press.

McLaughlin, D. G., Raymonda, J. S., Murakami, S. R., & Goebert, D. (1987). Drug use among

Asian Americans in Hawaii. Journal of Psychoactive Drug, 19(1), 85-94.

Mena, F. J., Padilla, A. M., & Maldonado, M. (1987). Acculturative stress and specific coping

strategies among immigrants and later generation college students. Hispanic Journal of

Behavioral Sciences, 9(2), 207-225.

Mental Health Services Administration (Ed.),Cultural Competence for Evaluators: A guide for

alcohol and other drug abuse prevention practitioners working with ethnic/racial

135

communities(OSAP Cultural Competence Series I, DHHS. Publication No. [SAM]95-

3066, pp. 203-260).Rockville, MD: SAMHSA.

Mercado, M. M. (2000). The invisible family: Counseling Asian American substance abusers

and their families. The Family Journal, 8(3), 267-272.

Moon, S. S., & DeWeaver, K. L. (2005). An empirical test of the Multicultural/Multimodal/

Multisystem (MULTI-CMS): Approach for Korean immigrant families. Journal of Social

Work Research and Evaluation, 6(1), 57-74.

Mulia, N., Schmidt, L, Bond, J. Jacobs, L., & Korcha, R. (2008). Stress, social support and

problem drinking among women in poverty. Addiction, 103(8), 1283-1293.

Mullen, K., Blaxter, M., & Dyer, S. (1986). Religion and attitude towards alcohol use in the

Western Isles. Drug and Alcohol Dependence, 18(1), 51-72.

Mulvaney-Day, N. E., Alegria, M., & Sribney, W. (2007). Social cohesion, social support, and

health among Latinos in the United States. Social Science & Medicine, 64, 477-495.

Nadal, K. L. (2000). F/Pilipino American substance abuse: Sociocultural factors and methods of

treatment. Journal of Alcohol and Drug Education, 46, 26-36.

National Asian Pacific American Families Against Substance Abuse (NAPAFASA). (2005).

Alcohol, tobacco, and other drug fact sheet: Asian American and Pacific Islanders.

Retrieved February 15, 2007 from

http://www.napafasa.org/resources/doc/ATOD%20Fact%20Sheet.doc.

National Association of Social Workers (NASW) (2003). Practice research network. Retrieved

April 25, 2010,from http://www.socialworkers.org/naswprn/surveyOne/demogr.pdf

National Institute on Drug Abuse (2005). Info facts: treatment trends. Retrieved February 15,

2007 from http://www.drugabuse.gov/PDF/InfoFacts/TreatmentTrends05.pdf.

136

Nemoto, T., Huang, K., & Aoki, B. (1998). Strategies for accessing and retaining Asian drug

users in research studies. In M. R. De La Rosa, B. Segal, & R.Lopez (Eds.), Conducting

drug abuse research with minority populations Advances and issues (pp. 151-165).New

York: Haworth Press.

Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: Moderating effects of

coping, acculturation, and ethnic support. American Journal of Public Health, 93 (2),

232-238.

Noh, S., Kaspar, V., Hou, F., & Rummens, J. (1999). Perceived racial discrimination, depression,

and coping: A study of Southeast Asian Refugees in Canada. Journal of Health and

Social Behavior, 1999, 40, 193-207.

Oh, Y., Koeske, G., & Sales, E. (2002). Acculturation, stress, and depressive symptoms among

Korean immigrants in the United States. Journal of Social Psychology, 142, 511-526.

Parrish, M. (1995). Alcohol abuse prevention research in Asian American and Pacific Islander

communities. In P. A. Langton, L.G. Epstein, & M.A. Orlandi (Eds.), The challenge of

participatory research: Preventing alcohol-related problems in ethnic communities.

Special collaborative NIAAA/CSAP monograph based on a NIAAA conference May 18-

19, 1992 (pp. 389-409). Rockville, MD: US Department of Health and Human Services.

Peele, S. (1986). The implications and limitations of genetic models of alcoholism and other

addictions. Journal of Studies on Alcohol, 47 (1), 63-73.

Pennell, B., Bowers, A., Carr, D., Chardoul, S., Cheung, G. Dinkelmann, K.,. . .Torres, M.

(2004). The development and implementation of the National Comorbidity Survey

Replication, the National Survey of American Life, and the National Latino and Asian

137

American Survey. International Journal of Methods in Psychiatric Research, 13, 241-

269.

Phelps, R. E., Taylor, J. D., & Gerard, P.A. (2001). Cultural mistrust, ethnic identity, racial

identity, and self-esteem among ethnically diverse black students. Journal of Counseling

& Development, 79(2), 209-216.

Phinney, J. S. (1996). Stages of ethnic identity development in minority group adolescents. The

Journal of Early Adolescence, 9(1-2), 34-49.

Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic identity, immigration,

and well-being: An interactional perspective. Journal of Social Issues, 57(3), 493-510.

Phinney. J. S. (2003). Ethnic identity and acculturation. In K. M.Chun, P. B. Organista, & G.

Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research (pp.

63-82). Washington, DC: American Psychological Association.

Platt, A., Sloan, F. A., & Costanzo, P. (2010). Alcohol-consumption trajectories and associated

characteristics among adults older than age 50. Journal of Studies on Alcohol and Drug,

71 (2), 169-179

Preze, D. J., Fortuna, L., & Alegria, M. (2008). Prevalence and correlated of everyday

discrimination among U.S. Latinos. Journal of Community Psychology, 36(4), 421-433.

Price, R. K., Risk, N. K., Wong, M.M., & Klingle, R. S. (2002). Substance use and abuse by

Asian Americans and Pacific Islander: Preliminary results from four national

epidemiological studies. Public Health Reports, 117, S39-S50.

Puddey, I. B., Rakic, V., Dimmitt, S. B., & Beilin, L. J. (1999). Influence of pattern of drinking

on cardiovascular disease and cardiovascular risk factors: a review. Addiction, 94(5),

649-663.

138

Pugh, L. A. & Bry, B. (2007). The protective effects of ethnic identity for alcohol and marijuana

use among Black young adults. Cultural Diversity and Ethnic Minority Psychology,

13(2), 187-193.

Recio Adrados, J. (1993).Acculturation: The broader view. In M. R. D. LaRosa, J. Recio Adraos

(Ed.), Drug abuse among minority youth: Methodological issues and recent research

advances (NIAAA Research Monograph 130 NIH Publication No. 93-3479 pp. 57-78).

Rockville, MD: NIAAA.

Reeves, T. J., & Bennett, C. E. (2004). We the people: Asians in the United States. Census 2000

Special Report. Retrived from August 15, 2009,

http://www.census.gov/prod/2004pubs/censr-17.pdf.

Rehm J., Gmel, G., Sempos, C. T., & Trevisan, M (2003a). Alcohol-related morbidity and

mortality. Alcohol Research & Health, 27(1), 39-51.

Rehm, J., Room, R., Graham, K., Monteiro, M., Gmel, G., & Sempos, C. T. (2003b). The

relationship of average volume of alcohol consumption and patterns of drinking to burden

of disease: an overview. Addiction, 98, 1209-1228.

Ringwalt, C., Graham, P., Sanders-Phillips, K., Browne, D., & Paschall, M. (1999). Ethnic

identity as a protective factor in the health behaviors of African-American male

adolescent. In S. B. Kar (Ed.), Substance abuse prevention: A multicultural perspective

(pp. 131-151). Amityville, NY: Baywood.

Ro, M. (2009). The workforce. In C. Trinh-Shevrin, N. S. Islam, & M. J. Rey, Asian Americans

communities and health: context, research, policy, and action (pp. 549-566). San

Francisco, CA: Jossey-Bass.

Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet, 365(9458), 519-530.

139

Root, M. P. P. (2005). Filipino families. Chinese Families. In M. McGoldrick, J. Giordano, & N.

Garcia-Preto (Eds.). (3rd ed.), Ethnicity and family therapy (pp. 319-331). New York:

The Guilford Press.

Russell, M., Light, J. M., & Gruenewald, P. J. (2004). Alcohol consumption and problems: the

relevance of drinking patterns. Alcoholism: Clinical and Experimental Research, 28(6),

921-930.

Sakai, J. T., Ho, P.M., Shore, J. H., Risk, N. K., & Price, R. K. (2005). Asians in the United

States: Substance dependence and use of substance-dependence treatment. Journal of

Substance Abuse Treatment, 29, 75-84.

Salagado de Snyder, V. N. (1987). Factors associated with acculturative stress and depressive

symptomatology among married Mexican immigrant women. Psychology of Women

Quarterly, 11, 475-488.

Salant, T., & Lauderdale, D. S. (2003). Measuring culture: A critical review of acculturation and

health in Asian immigrant populations. Social Science & Medicament, 57, 71-90.

Sayette, M. A. (1999). Does drinking reduce stress? Alcohol Research & Health, 23(4), 250-255.

Schoenborn, C. A., & Adams, P. F. (2002). Alcohol use among adults: United States, 1997-98.

Advance Data 324.Retrived March 6, from http://www.cdc.gov/nchs/data/ad/ad324.pdf

Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity in perceived racial

discrimination. Journal of Personality and Social Psychology, 84(5), 1079-1092.

Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, M. A., & Zimmerman, M. A. (2003). Racial

identity, racial discrimination, perceived stress, and psychological distress among African

American Young Adults. Journal of Health and Social Behavior, 44(3), 302-.317

140

Shannon, M.T. (1989). Health promotion and illness prevention: a biopsychosocial perspective.

Health and Social Work, 14, 32-40.

Shen, B., & Takeuchi, D. T. (2001). A structural model of acculturation and mental health status

among Chinese Americans. American Journal of Community Psychology, 29(3), 387-

418.

Shin, S., & Hutton, E. M. (2002). Working with Korean immigrants alcohol abusing clients: a

sociocultural approach. Journal of Immigrants and Refugee Services, 1(2), 1-19.

Siegel, K., Anderman, S. J., & Schrimshaw, E. W. (2001). Religion and coping with health-

related stress. Psychology and Health, 16, 631-653.

Smith, M. J. W. (2005, Winter). Developing a social work labor force to meet the increasing

demand for substance abuse services in the United States. SPS Practice Update, 1-2.

Retrieved from May 12, 2010, www.nasw.org.

Smokowski, P. R., David-Ferdon, C., & Stroupe, N. (2009). Acculturation and violence in

minority adolescents: A review of the empirical literature. Journal of Primary Prevention,

30, 215-263

So, D. W, & Wong, F. Y. (2006). Alcohol, drugs, and substance use among Asian-American

college students. Journal of Psychoactive Drugs, 38(1), 35-42.

Sodowsky, G. R., Lai, E. W., & Plake, B. S. (1991). Moderating effects of sociocultural

variables on acculturation attitudes of Hispanic and Asian Americans. Journal of

Counseling and Development, 70, 194-204.

St. Lawrence, J. S., Brasfiedl, T. L., Jefferson, K. W., Allyene, E., & Shirely, A. (1994). Social

support as a factor in African-American adolescents’ sexual behavior. Journal of

Adolescent Research, 9(3), 292-310.

141

StataCorp. (2007). Stat statistical software: Release 10. College Station, TX: Statacorp LP.

Stockdale, S. E., Wells, K. B., Tang, L., Belin, T. R., Zhang, L., & Sherbourne, C. D. (2007).

The importance of social context: neighborhood stressors, stress-buffering mechanisms,

and alcohol, drug, and mental health disorders. Social Science and Medicine, 65(9),

1867-1881.

Subramanian, S. K., & Takeuchi, D. (1999). The complexities of diversity: Substance abuse

among Asian Americans. In S. B. Kar (Ed.), Substance abuse prevention: A multicultural

perspective (pp. 185-198). Amityville, NY: Baywood.

Substance Abuse and Mental Health Service Administration (1998). Prevalence of substance use

among racial and ethnic subgroups in the United States 1991-1993. Rockville, MD:

Office of Applied Studies, SAMHSA.

Substance Abuse and Mental Health Service Administration (2003). SAMHSA Newsletter XI(3).

Retrieved December 9, 2009 from

http://www.samhsa.gov/samhsa_news/volumeXI_3/article9.htm

Substance Abuse and Mental Health Service Administration (2004). Results from the 2003

National Survey on Drug Use and Health: National Findings. NSDUH Series, H-

25.Rockville, MD: Office of Applied Studies, SAMHSA.

Substance Abuse and Mental Health Service Administration (2007). Results from the 2006

National Survey on Drug Use and Health: National Findings. Retrieved December 10,

2009 from http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.

Sue, S., & Nakamura, C. Y. (1984). An integrative model of physiological and

socio/psychological factors in alcohol consumption among Chinese and Japanese

Americans. Journal of Drug Issues, 14(2), 349-364.

142

Sue, S., Zane, N., & Ito, J. (1979). Alcohol drinking patterns among Asian and Caucasian

Americans. Journal of Cross-Cultural Psychology, 10(1), 41-56.

Suinn, R. M., Rickard-Figueroa, K., Lew, S., &Vigil, P. (1987). The Suinn-Law Asian Self-

Identity Acculturation Scale: An initial report. Educational and Psychological

Measurement, 47, 401-407.

Sustento-Senirches, J. (1997). Filipino American families. In E. Lee (Ed.), Working with Asian

Americans: A guide for clinicians (pp. 101-113). New York: The Guildford Press.

Syme, S. L., & Yen, I. H. (2000). Social epidemiology and medical sociology: Different

approaches to the same problem. In E.C. Brid, P. Conrad, & A. M. Fremont (Eds.),

Handbook of medical sociology (pp. 365-376). Upper Saddle River, NJ: Prentice-Hall.

Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.) (2007). Boston,

MA: Pearson Education, Inc.

Takeuchi, D. T., Hong, S, Gile, K., & Alegria, M. (2007). Developmental contexts and mental

disorders among Asian Americans. Research in Human Development, 4(1&2), 49-69.

Takeuchi, D. T., Zane, N., Hong, S, Chae D., Gong, F., Gee, G., Walton, E., Sue, S., & Alegria,

M. (2007). Immigration-related factors and mental disorders among Asian Americans.

American Journal of Public Health, 97(1), 84-90.

Thompson, R. A., & Flood, M. F., & Goodvin, R. (2006). Social support and developmental

psychopathology. In D. Cicchetti & D. J. Cohen, Developmental psychopathology (2nd

ed.). (pp. 1-37). Hoboken, NJ: John Wiley & Sons Inc.

Thurman, P. J., Plested, B., Edwards, R. W., Chen, J., & Swaim, R. (2000) Intervention and

treatment with ethnic minority substance abusers. In J. Aponte & J. Wohl (Eds.),

143

Psychological intervention and cultural diversity (2nd ed., pp. 214-249), Needham

Heights, Massachusetts: Allyn & Bacon .

Trimble, J. E. (2003). Social change and acculturation. In K. M. Chun, P. B. Organista, & G.

Marin (Eds.), Acculturation: Advance in theory, measurement, and applied research (pp.

3-14). Washington, DC: American Psychological Association.

Tsunoda, T., Parrish, K., Higuchi, S., Stinson, F. S., Kono, H., Ogata, M., & Harford, T. C.

(1992). The effects of acculturation on drinking attitudes among Japanese in Japan and

Japanese Americans in Hawaii and California. Journal of Studies on Alcohol, 53(4), 369-

377.

U.S. Department of Health and Human Services (2001). Mental health: Culture, race, and

Ethnicity-- a supplement to mental health. A report of the Surgeon General. Rockville,

MD: U.S. Department of Health and Human Services, Substance Abuse and Mental.

U.S. Department of Health and Human Services (2009, June 10). Cancer and Asians/Pacific

Islanders. Retrieved from

http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=53&ID=3055

U.S. Department of Health and Human Services (2010a , March 14). Healthy People 2000.

Alcohol and other drugs. Retrieved from

http://lancaster.ne.gov/City/HEALTH/hp2010/Alcoth.pdf

U.S. Department of Health and Human Services (2010b, March 14). Health People 2010

Retrieved from http://www.healthypeople.gov/About/hpfact.htm

Uba, L. (1994). Asian Americans: Personality patterns, identity, and mental health. New York,

NY: The Guilford Press.

144

Varma, S. C., & Siris, S. G. (1996). Alcohol abuse in Asian Americans: Epidemiological and

treatment issues. The American Journal on Addictions, 5, 136-143.

Vega, W. A., & Gill, A. G. (1999). A model for explaining drug use behavior among Hispanic

adolescents. In M. R. De La Rosa, B. Segal, & R. Lopez (Eds.), Drug abuse research

with minority populations: Advances and issues (pp. 57-74). New York: New York Press,

Inc.

Vega, W., Zimmerman, R., Warheit, G., & Gil, A. (2003). Acculturation, stress and Latino

adolescent drug use. Retrieved March 13, 2009, from

http://www.mhsip.org/pdfs/Vega.pdf

Wall, T. L., & Ehlers, C. L. (1995). Genetic influences affecting alcohol use among

Asian.Alcohol Health and Research World, 19, 184-189.

Wei, M., Heppner, P. P., Mallen, M., Ku, T. Y., Liao, K. Y. H., & Wu, T. F. (2007).

Acculturative stress, perfectionism, years in the United States, and depression among

Chinese international students. Journal of Counseling Psychology, 54, 385-394.

White, H. (1980). A heteroskedasticity-consistent covariance matrix estimator and a direct test

for heteroskedasticity. Econometrica, 48 (4), 817-838.

Wills, T. A. (1990). Stress and coping factors in the epidemiology of substance use. In L. T.

Kozlowski, H. M. Annis, H. D. Cappell, F. B. Glaser, M. S. Goodstadt, Y. Israel et al

(Eds.), Research advances in alcohol and drug problems (pp.215-250). New York:

Plenum.

Wills, T. A., & Shiffman, S. (1985). Coping and substance use: A conceptual framework. In S.

Shiffman & T. A. Wills (eds.), Coping and substance use (pp. 3-24). Orlando, FL:

Academic Press.

145

Wills, T. S., Yaeger, A. M., & Sandy, J. M. (2003). Buffering effect of religiosity for adolescent

substance use. Psychology of Addictive Behavior, 17(1), 24-31

Wong, F. Y., Huang, Z. H., Thompson, E. E., De Leon, J. M., Shah, M. S., Park, R. J., & Do, T.

D. (2007). Substance use among a sample of foreign-and U.S.-born Southeast Asians in

an urban setting. Journal of Ethnicity in Substance Abuse, 6(1), 45-66.

Xu, Y. M., Ross, C., Ryan, R., & Wang, B. (2005). Cancer risk factors of Vietnamese Americans

in rural South Alabama. Journal of Nursing Scholarship, 3, 237-244.

Yancey, A. K., Aneshensel, C. S., & Driscoll, A. K. (2001). The assessment of ethnicity identity

in a diverse urban youth population. Journal of Black Psychology, 27, 190-208.

Yi, J. K. & Danile, A. M. (2001). Substance use among Vietnamese American college students.

College Student Journal, 35(1), 13-23.

Yip, T., Gee, G. C., & Takeuchi, D. T. (2008). Racial discrimination and psychological distress:

The impact of ethnic identity and age among immigrant and United States-born Asian

Adults. Developmental Psychology, 44(3), 787-800.

Yoo, H. C., Gee, G. C., Lowthrop, C. K., & Robertson, J. (2009). Self-reported racial

discrimination and substance use among Asian Americans in Arizona. Journal of

Immigrant and Minority Health, doi: 10.1007/s10903-009-9306-z

Yoshikawa, H., Wilson, P. A., Chae, D. H., & Cheng, J. (2004). Do family and friendship

networks protect against the influence of discrimination on mental health and HIV risk

among Asian and Pacific Islander gay men? AIDS Education and Prevention, 16(1), 84-

100.

Young, K., & Takeuchi, D. T. (1998). Racism. In L. C. Lee & W. S. Nolan (Eds.), Handbook of

Asian American psychology (pp. 401-432). Thousand Oaks, CA: Sage

146

Yu, J., Clark, L. P., Chandra, L., Dias, A., & Lai, T. F. M. (2009). Reducing cultural barriers to

substance abuse treatment among Asian Americans: a case study in New York City.

Journal of Substance Abuse Treatment, 37(4), 398-406.

Yu, S. M., & Vyas, A. N. (2009). The health of children and adolescents. In C. Trinh-Shevrin, N.

S. Islam, & M. J. Rey, Asian Americans communities and health: context, research,

policy, and action (pp. 107-131). San Francisco, CA: Jossey-Bass.

Zamboanga, B. L., Raffaelli, M., & Horton, N. J. (2006). Acculturation status and heavy alcohol

use among Mexican American college students: Investing the moderating role of gender.

Addictive Behaviors, 31, 2188-2198.

Zane, N. W. W., & Huh-Kim, J. (1998). Addictive behaviors. In L. C. Lee & N. W. S. Zane

(Eds.), Handbook of Asian American psychology (pp. 527-554). Thousand Oaks, CA:

Sage.

Zane, N., & Huh- Kim, J. H. (1994). Substance use and abuse. In N.W. S. Zane, D. T. Takeuchi,

& K. N. J. Young (Eds.), Confronting Critical Health Issues of Asian and Pacific

Islander Americans (pp. 316-346). Thousand Oaks, CA: Sage Publication.

Zane, N., & Mak, W. (2003). Major approaches to the measurement of acculturation among

ethnic minority populations: A content analysis and an alternative empirical strategy. In

K. M.Chun, P. B. Organista, & G. Marin (Eds.), Acculturation: Advance in theory,

measurement, and applied research (pp. 39-60). Washington, DC: American

Psychological Association.

Zane, N., & Sasso, T. (1992). Research on drug abuse among Asian Pacific Americans. In J.E.

Trimble, C.S. Bolek, & S. J. Niemcryk (Eds.), Ethnic and multicultural drug abuse:

perspective on current research (pp.181-205). New York: Haworth Press.

147

Zimmerman, R. S., Vega, W. A., Gil, A. G., Warheit, G. J., Apospori, E., & Biafora, F. (1994).

Who is Hispanic? Definitions and their consequences. American Journal of Public

Health, 84(12), 1985-1987.

148

Appendix A. Unfair treatment scale

In your day-to-day life how often have any of the following things happened to you? 1. You are treated with less courtesy than other people. (1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 2. You are treated with less respect than other people.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 3. You receive poorer service than other people at restaurant or stores

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 4. People act as if they think they are not smart.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 5. People act as if they are afraid of you.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day

149

6. People act as if you are dishonest.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 7. People act as if you are not as good as they are.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 8. You are called names or insulted.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day 9. You are threatened or harassed.

(1) Never (2) Less than once a year (3) A few times a year (4) A few times a month (5) At least once a week (6) Almost every day

150

Appendix B. Perceived racial/ethnic discrimination scale 1. How often do people dislike you due to your race/ethnicity? (1) Never (2) Rarely (3) Sometimes (4) Often 2. How often do people treat you unfairly due to your race/ethnicity?

(1) Never (2) Rarely (3) Sometimes (4) Often 3. How often have you seen friends treated unfairly due to their race/ethnicity?

(1) Never (2) Rarely (3) Sometimes (4) Often

151

Appendix C. Family conflict scale Please tell me how frequently the following situations have occurred to you. 1. You have felt that being too close to your family interfered with your goals.

(1) Hardly ever or never (2) Sometimes (3) Often 2. Because you have different customs, you have had arguments with other members of your family.

(1) Hardly ever or never (2) Sometimes (3) Often 3. Because of the lack of family unity, you have felt lonely and isolated.

(1) Hardly ever or never (2) Sometimes (3) Often 4. You have felt that family relations are becoming less important for people that you are close to.

(1) Hardly ever or never (2) Sometimes (3) Often 5. Your personal goals have been in conflict with your family.

(1) Hardly ever or never (2) Sometimes (3) Often

152

Appendix D. Statistical regression models in path analysis: Ordinal logistic and ordinary least squares (OLS) regression

153

Appendix E. IRB approval notice

New York University University Committee on Activities Involving Human Subjects 665 Broadway, Suite 804 New York, NY 10012 Telephone: 212-998-4808 / Fax: 212-995-4304 Internet: www.nyu.edu/ucaihs

UCAIHS APPROVAL NOTICE Initial Review

Date: 26-Jan-2010

PI Name: So-Youn Park HS#: (10-0041) "Socio-Cultural Factors Related to Alcohol Use Among Asian Americans" Sponsor: Number of Subjects Approved for enrollment: 2095 Devices:

Dear Investigator,

Your Initial Review submission was reviewed and approved following an Exempt review under category(s): 4.

Approval Date: 26-Jan-2010 Expiration Date: 25-Jan-2013

Please remember to use HS#(10-0041) on any documents or correspondence with the IRB concerning your research protocol.

Please note that the IRB has the prerogative and authority to ask further questions, seek additional information, require further modifications, or monitor the conduct of your research and the consent process.

We wish you the best as you conduct your research. If you have any questions or need further help, please contact the IRB office at (212) 998-4808 or email ask.humansubjects@nyu.edu

Sincerely,

UCAIHS STAFF New York University 665 Broadway, Suite 804 New York, NY 10012

154

Appendix F. Characteristics of Chinese, Filipino, and Vietnamese Americans in weighted sample size.

Chinese Filipino Vietnamese

n (%)/mean n (%)/mean n (%)/mean

Gender

Female 1,174,382 (52.5) 883,572 (52.5) 529,215 (52.5)

Male 1,060,443 (47.5) 797,848(47.5) 477,871 (47.5)

Marital status

Married 1,472,872 (65.9) 1,146,898 (68.2) 721,953 (71.7)

Divorced 226,587(10.1) 163,574 (9.7) 69,695 (6.9)

Never married 2,234,825 (24.0) 370, 948 (22.1) 215,439 (21.4)

Education

Less than high school 389,532 (17.4) 182,950 (10.9) 319,476 (31.7)

High school graduate 362,210 (16.2) 341,852 (20.3) 212,054 (21.1)

College 464,035 (20.8) 537,490 (32.0) 236,524 (23.5)

Graduate school 1,019,048 (45.6) 619,127 (36.8) 239,033 (23.7)

Religion

Protestantism 455,409 (20.5) 257,906 (15.5) 55,351 (5.5)

Catholic 174,758 (7.9) 1,194,573 (71.9) 330,369 (32.9)

Other religion 492,654 (22.2) 113,090 (6.8) 548,601 (54.7)

No religion 198,046 (49.4) 96,055 (5.8) 68,456 (6.8)

Generation

First generation 1,961,686 (88.1) 1,397,569 (83.1) 982,053 (97.8)

Second generation 92,727 (4.16) 147,561 (8.8) 21,755 (2.17)

Third generation 173,322 (7.74) 136,289 (8.1) 0

Family support

Yes 318,248 (85.7) 1,443,570 (86.1) 753,295 (75.2)

No 1,908,945 (14.3) 232,556 (13.9) 248,434 (24.8)

Friend support

Yes 1,989,955 (89.1) 1,484,198 (88.6) 745,360 (74.4)

No 243,234 (10.1) 190,549 (11.4) 245,369 (25.6)

Religiosity

Never 1,342,765 (60.5) 278,871 (16.8) 237,122 (23.6)

One to three times a month 575,380 (18.9) 574,439 (34.6) 448,512 (44.7)

Once a week or more 302,721 (13.6) 808,315 (48.6) 317,144 (31.6)

155

Alcohol use

Abstaining 1,369,627 (61.3) 746,825 (44.6) 720,859 (71.9)

Light-to-moderate drinking 798,051 (17.8) 833,758 (49.8) 258,180 (26.7)

Risky drinking 67,147 (3.0) 93,901 (5.6) 13,668 (1.4)

156

Appendix G. Correlation matrix among all variables among Chinese Americans

1 2 3 4 5 6 7 8 9 10

1. Alcohol use 1

2. Age -.21*** 1

3. Gender .31*** -.002 1

4. Income .15*** -.09* .11** 1

5. Education .14*** -.30*** .10* .32*** 1

6. Marital status .89* -.26*** -.08 -.23*** .04 1

7. Protestantism -.04 .07 -.03 -.02 .14*** .13** 1

8. Catholicism .11** .11** .05 -.01 -.01 -.01 -.15*** 1

9. Other religion -.01 .02 -.02 -.02 -.21*** -.03 .28*** -.15*** 1

10. No religion -.02 -.13** .02 .03 .06 -.08* .52*** -.27*** -.51*** 1

11. English proficiency .28*** -.37*** .09 .28*** .52*** .23*** .18*** .10* -.13** -.09*

12. Generation .24*** .03 .08 .02 .06 .09* .23*** .19*** -.11** .21***

13. Unfair treatment .21*** -.27*** .10* .16*** .18*** .18*** -.001 -.01 -.003 .01

14. Racial/ethnic discrimination .05 -.05 .01 .06 .04 -.004 -.08 -.07 .03 .08*

15. Family conflict .13** -.06 -.04 .03 .10* .18*** .01 .05 .02 -.05

16. Family support -.004 -.09* -.10* .12** .11** -.03 .04 .01 .002 -.04

17. Friend support -.08* -.28*** -.08*** .16* .19*** .14*** .04 -.05 .007 -.02

18. Religiosity -.10 .07 .08 -.05 -.07 .21*** .02 .07 -.25*** -.31***

*p < .05, **p < .01, <***p < .001

157

Appendix G. Correlation matrix among all variables among Chinese Americans continued

11 12 13 14 15 16 17 18

1. Alcohol use

2. Age

3. Gender

4. Income

5. Education

6. Marital Status

7. Protestantism

8. Catholicism

9. Other religion

10. No religion

11. English proficiency 1

12. Generation .34*** 1

13. Unfair treatment .28*** .09* 1

14. Racial/ethnic discrimination -.05 -.12** .37*** 1

15. Family conflict .13** .01 .31*** .21*** 1

16. Family support .04 .02 .04 .009 -.12** 1

17. Friend support .16*** .01 .17*** .12** .05 .37*** 1

18. Religiosity .08 -.04 -.07 -.01 -.14* .18*** .11* 1

*p < .05, **p < .01, ***p < .001

158

Appendix H. Correlation matrix among all variables among Filipino Americans

1 2 3 4 5 6 7 8 9 10

1. Alcohol use 1

2. Age -.30*** 1

3. Gender .38*** .005 1

4. Income .07 -.004 .07 1

5. Education .06 -.16*** -.01 .30*** 1

6. Marital Status .11* -.31*** -.08 -.23*** -.05 1

7. Protestantism -.03 -.04 -.02 .05 -.02 -.04 1

8. Catholicism -.05 .08 -.01 -.0002 .04 .02 -.71*** 1

9. Other religion .05 .04 .03 -.05 -.07 -.06 -.12** -.43*** 1

10. No religion .10* -.14** .03 -.03 .01 .10* -.10* -.36*** -.06 1

11. English proficiency .22*** .32*** -.02 .17*** .44*** .15*** -.009 -.03 -.02 .11*

12. Generation .16*** .21*** .03 -.09* -.07 .10* .05 -.19*** .13** .15***

13. Unfair treatment .16*** .17*** .17*** .05 .09* .009 .09 -.10* .04 .01

14. Racial/ethnic discrimination -.03 .05 .08 .04 .14** -.06 .05 -.003 -.04 -.04

15. Family conflict .01 -.09* -.09 -.02 .05 .03 .08 -.08 .042 -.01

16. Family support .04 -.09* -.04 .06 .11* .007 .003 .07 -.10* -.04

17. Friend support .05 -.32*** -.07 .08 .23*** .11* .004 -.001 -.02 -.01

18. Religiosity -.25*** .29*** -.08 .04 .12** -.20*** .15*** -.03 -.02 -.24***

*p < .05, **p < .01, ***p < .001

159

Appendix H. Correlation matrix among all variables among Filipino Americans continued.

11 12 13 14 15 16 17 18

1. Alcohol use

2. Age

3. Gender

4. Income

5. Education

6. Marital Status

7. Protestantism

8. Catholicism

9. Other religion

10. No religion

11. English proficiency 1

12. Generation .14** 1

13. Unfair treatment .03 .13** 1

14. Racial/ethnic discrimination -.03 -.04 .51*** 1

15. Family conflict .005 -.03 .34*** .23*** 1

16. Family support .01* -.09 .02 .02 -.10* 1

17. Friend support .24*** .05 .11** .07 .04 .46*** 1

18. Religiosity -.12* -.18*** -.07 .10* .01 .09* -.04 1 *p < .05, **p < .01, ***p < .001

160

Appendix I. Correlation matrix among all variables among Vietnamese Americans

1 2 3 4 5 6 7 8 9 10

1. Alcohol use 1

2. Age -0.10* 1

3. Gender .37*** .02 1

4. Income .16*** -.12** .07 1

5. Education .14** -.29*** .20*** .33*** 1

6. Marital status .06 -.31*** .02*** -.20*** .01 1

7. Protestantism -.06 -.07 -.03 .04 .01 .09* 1

8. Catholicism -.02 .01 .01 -.06 -.02 -.04 -.16*** 1

9. Other religion -.02 .06 -.03 .004 .001 -.03 -.24*** -.78*** 1

10. No religion .12** -.09* .08 .06 .03 .06 -.06 -.20*** -.30*** 1

11. English proficiency .22*** -.50*** .12** .36*** .56*** .21*** .12** -.04 -.06 .10*

12. Generation .03 -.011* .01 -.03 -.13* -.02 .23*** .05 -.15*** .02

13. Unfair treatment .28*** -.28*** .16*** .16*** .19*** .21*** .11* -.04 -.06 .08

14. Racial/ethnic discrimination .23*** -.15*** .06 .018*** .23*** .09* .04 .05 -.11* .07

15. Family conflict .16*** -.20*** .01 .09* .12** .25*** .07 .0 -.06 .03

16. Family support .07* -.04 -.006 .20*** .13*** -.07 -.06 .03 .02 -.04

17. Friend support .13** -.17*** .04 .21*** .22*** .06 -.01 .04 -.02 -.03

18. Religiosity -.12** .04 -.06 -.09* .01 .01 .21*** .59 -.62*** -.16***

*p < .05, **p < .01, ***p < .001

161

Appendix I. Correlation matrix among all variables among Vietnamese Americans continued.

11 12 13 14 15 16 17 18

1. Alcohol use

2. Age

3. Gender

4. Income

5. Education

6. Marital status

7. Protestantism

8. Catholicism

9. Other religion

10. No religion

11. English proficiency 1

12. Generation .08 1

13. Unfair treatment .30*** .02 1

14. Racial/ethnic discrimination .17*** -.04 .47*** 1

15. Family conflict .20*** .01 .42*** .24*** 1

16. Family support .13** -.02 .08 .12** .03 1

17. Friend support .21*** -.04 .13** .15*** .10** .35*** 1

18. Religiosity -.04 .07 .01 .07 -.001 .01 .03 1

*p < .05, **p < .01, ***p < .001

162

Appendix J. Direct as well as indirect paths from generation to alcohol use

The indirect effect of third generation on alcohol use is estimated by the product of two

path coefficients, ΔR2 ge * ΔR 2

ed, because the indirect effect is estimated by product of the direct

effects. The indirect effect of the third generation status on alcohol use is estimated by

multiplying the direct effect of the third generation status on unfair treatment (ΔR2 ge) by the

direct effect of unfair treatment on alcohol use (ΔR2ed):

Indirect effect: ΔR2 ge (0.02) * ΔR 2

ed (0.003) = 0.00006, in terms of ΔR 2.

Third generation

Unfair treatment

Alcohol use

Direct effect: R2 gd

R2 ge =0.02 R 2

ed =0.003