A meta‐analytic study: The relationship between acculturation and depression among Asian Americans

A Meta-Analytic Study: The Relationship BetweenAcculturation and Depression Among Asian Americans

Arpana GuptaUniversity of California Los Angeles

Frederick LeongMichigan State University

Jeffrey C. Valentine and Dericka D. CanadaUniversity of Louisville

Acculturation is an important and popular cultural research variable among specific eth-nic populations that is used to explain the process of assimilating into the host culture.Acculturation has often been used to account for psychosocial changes and health out-comes and has been used to explain health disparities among ethnic groups. Using Asian

Americans as an illustrative ethnic group, the authors see that researchers have high-lighted the influence of acculturation on health outcomes. Some researchers suggest thatthis relationship is positive, whereas others postulate that the opposite is true. Because of

the highly complex and divergent findings in the literature, this meta-analysis addressesthe question of how acculturation (as measured by acculturation scales) is related todepression (a specific mental health outcome) among the Asian American population liv-

ing in North America. Analyses were based on 38 studies. The meta-analyses reveal thatwhen acculturation is measured as assimilation to the American culture, there is a smallbut statistically significant negative relationship between acculturation and depression

scores. When acculturation is measured as orientation to the Asian culture, the relation-ship between acculturation and depression scores is also negative, but not statisticallysignificant.

Acculturation is a major cultural variable that impactsthe health outcomes of various ethnic groups. Because

research has demonstrated that culture can act as anantecedent to health status among ethnic minorities in America,and with recent attention to poorer health outcomes among

ethnic groups, this has become the focus of many researchefforts. Using Asian Americans as an illustrative sample, we seethat the acculturation research is divergent. For example, some

studies have demonstrated that increased assimilation into theAmerican culture appears to be inversely correlated to morbid-ity (e.g., Cheung, 1995; Takeuchi et al., 1998), whereas otherstudies have demonstrated that high orientation to the Ameri-

can culture is associated with an increase in psychiatric disor-ders (e.g., Guglani, Coleman, & Sonuga-Barke, 2000; Nguyen& Peterson, 1993) and increased risk of chronic disease (e.g.,

Fujimoto et al., 2000).The aim of this meta-analysis is to quantitatively synthesize

the disparate acculturation data in a specific health outcome

(depression) that has acute as well as chronic mental health

implications for Asian Americans. We used Suinn-Lew’s two-dimensional acculturation model as the basis for our study

(Leong & Chou, 1994). Suinn-Lew’s model is based on Berry’s(1980) model, which is the most prominent and well-acceptedacculturation model in the literature to date. Development of

the Suinn-Lew Asian Self-Identity Acculturation Scale(SL-ASIA; Suinn, Ahuna, & Khoo, 1992; Suinn, Rickard-Fig-uerora, Lew, & Vigil, 1987) is based on this model and moves

along a continuum of low (orientation to Asian culture) versushigh acculturation (orientation to American culture). Table 1(four-quadrant multidimensional model; Leong & Chou, 1994)summarizes the various acculturation models in the literature

(Berry, 1980; Cross, 1991; Sue & Sue, 1973) and highlights howSuinn-Lew’s acculturation model maps onto these otheracculturation models. Because of the popularity of multidimen-

sionality and comprehensiveness associated with scaled accul-turation measures, only studies that used scaled acculturationmeasures were identified and analyzed for the purposes of this

investigation. The results from this meta-analysis will helpquantitatively synthesize the divergent findings associated withacculturation and depression, so that researchers and practi-tioners can identify and highlight the gaps present in the cur-

rent theoretical conceptualization and measurement issuesassociated with acculturation scales related to specific healthoutcomes. Hence, future acculturation studies can be improved.

This line of investigation becomes even more valuable within

The authors would like to acknowledge Gilbert Gee and Fred

Oswald for their extensive feedback on various iterations of this article.

Correspondence concerning this article should be addressed to

Arpana Gupta, Semel Institute at UCLA, Psychiatry and Bio-Behav-

ioral Sciences, 760 Westwood Plaza, #28-261, Los Angeles, CA 90024.

Electronic mail may be sent to [email protected].

American Journal of Orthopsychiatry © 2013 American Orthopsychiatric Association2013, Vol. 83, No. 2,3, 372–385 DOI: 10.1111/ajop.12018

372

the context of the notion that acculturation levels help explainhealth disparities and health outcomes that are associated withcultural factors related to behavior or lifestyle (Dressler, 1993).

Acculturation

Definition, Conceptualization, andDimensionality of Acculturation

Acculturation is a widely accepted and adopted multidimen-sional cultural process that is used in various disciplines suchas anthropology, sociology, epidemiology, and psychology

(Salant & Lauderdale, 2003). Despite its widespread use, accul-turation remains undefined and undifferentiated in the healthliterature (Hunt, Schneider, & Comer, 2004; Leong & Chou,

1994). On a broad and basic level, acculturation defines theprocess involved when groups from two different cultures comeinto contact with each other and subsequently experience

changes in either or both groups of individuals (Berry, 1980;Redfield, Linton, & Herskovits, 1936). In other words, accul-turation consists of the confluence of values, practices, and

identifications between the heritage culture and the host orreceiving culture (Schwartz, Unger, Zamboanga, & Szapocznik,2010). However, individuals are a product of both the socialroles they are assigned and the choices they make within the

constraints of their roles and the context of their society atlarge (Schwartz, Unger, Zamboanga, & Szapocznik, 2011).Examples include drinking at the age of 18, entering careers

that are acceptable for their gender, or choosing a collegemajor that is popular. However, this conceptualization of accul-turation seems vague and nebulous in that specifics regarding

the change process or the original cultural traits are not spelledout (Hunt et al., 2004). In addition, this viewpoint assumes thatacculturation occurs in a linear and unidirectional way and that

acculturation is regarded as a distinctive outcome rather thanas a complex, dynamic, multidimensional, and overarching con-struct that can be studied in different ways for different racial,ethnic, and cultural groups (Abe-Kim, Okazaki, & Goto, 2001;

Ryder, Alden, & Paulhus, 2000). Moyerman and Forman(1991) also stressed that acculturation cannot be limited to onesingle dimension of human experience, as it is a process that

involves cognitions, attitudes, behaviors, and values.

Measurement of Acculturation

Currently, there is no consensus regarding the precise defini-tion and conceptualization of acculturation. This can only

translate to further problems, especially with regard to mea-surement (Chun, Organista, & Marin, 2003; Rogler, Cortes, &Malgady, 1991; Zane & Mak, 2003). The measurement of

acculturation has depended on the following two mainmethods: proxy measures and scaled measures.

Proxy measures. Proxy measures of acculturation use asingle item or a few items to tap into specific “domains” associ-ated with cultural change (e.g., generation status, number of

years in America, language preference, group affiliation). Theseindirect measures of acculturation are widely used and oftenare the preferred method of measurement in many studies, in

part because of their efficiency (i.e., indirect measures tend tobe less expensive to collect because of the limited time andeffort associated with answering a few questions vs. multi-itemand multidimensional questionnaires). However, these indirect

methods of measuring acculturation often lack any explicit the-oretical model (Salant & Lauderdale, 2003). These methodsalso highlight a concern related to the content validity of the

measures (Gee, Walsermann, & Takeuchi, 2010; Hunt et al.,2004; Zane & Mak, 2003). In addition, proxy measures oftendemonstrate low reliabilities and capture limited dimensions of

acculturation because of the utilization of a small number andrange of questions. Despite these distinctions, researchers con-tinue to measure acculturation through these proxy measures.

Scaled measures. Although scaled measures of accultur-ation would appear to be better than indirect measures, as they

are usually based on a theoretical model and consist of agreater range of items to capture a more complete picture ofacculturation (Salant & Lauderdale, 2003), the reality suggests

otherwise. The reasons for the shortcomings associated withscaled acculturation measures follow.Many scales used with Asian Americans were created or

adapted from similar scales created for other ethnic groups

such as Latinos and Hispanics (Cueller, Arnold, & Maldonado,1995; Liem, Lim, & Lien, 2000). Although the Latino andHispanic culture has comparative similarities to the Asian cul-

ture, clear differences in histories, context, and socioculturalbackgrounds cannot be ignored. It seems likely that using thesemeasures for Asians will result in certain important aspects of

acculturation being omitted.More recently, to address this issue of developing scales spe-

cific for the groups for which they are intended, some scaledmeasures of acculturation have been created specific for Asian

Americans (e.g., SL-ASIA; Suinn et al., 1987, 1992). In fact, theSL-ASIA is one of the most widely used acculturation measuresin Asian American studies (see Table 1). Similar to the

SL-ASIA, there are other scaled acculturation measures that aredesigned to yield one summary score, and, therefore, theymeasure acculturation as some endpoint outcome on a linear

unidimensional scale. The unidimensional model is based on theassumption that, over time, change in cultural identity takesplace on a continuum from low U.S. acculturation to high U.S.

acculturation. The unidimensional model also assumes that the

Table 1. An Integrated Acculturation Model of Racial andEthnic Identity

Host culture

Own culture

Positive Negative

Positive 1a. Integration 1b. Assimilation

2a. Asian American 2b. Marginal man

3a. Medium acculturation 3b. High acculturation

4a. Internalization 4b. Pre-encounter

Negative 1c. Separation 1d. Marginal

2c. Traditionalist

3c. Low acculturation

4c. Encounter/Immersion

1 = Berry’s model; 2 = Sue and Sue’s model; 3 = Suinn-Lew’s model;

4 = Cross’s model.

META-ANALYSIS: ACCULTURATION AND DEPRESSION 373

heritage culture is negatively correlated with the mainstreamU.S. culture (Ryder et al., 2000). Unfortunately, although con-sidered inaccurate and incomplete, the unidimensional model

has been used more often to measure acculturation versus the bi-dimensional or multidimensional models. For example, in a con-tent analysis, Zane and Mak (2003) found that 14 of the 21

studies used acculturation measures that were unidimensional innature.In contrast to the unidimensional perspective, efforts have

been made to capture the bidimensional aspects of accultura-tion such as in the Vancouver Index of Acculturation (VIA;Ryder et al., 2000) and, relatedly, the SL-ASIA was revised tomore accurately reflect the multidimensional aspects of accul-

turation (Suinn et al., 1992). The bidimensional model of accul-turation posits that the two cultural identities (assimilation toU.S. culture vs. orientation to Asian culture) are independent

of each other. As such, this model suggests that individuals canadapt cultural characteristics of both cultures without necessar-ily relinquishing one cultural identity for another. The literature

has debated the merits and drawbacks of both these models,but recently, research has suggested that the bidimensionalmodels of acculturation are more useful and valid (Ryder et al.,

2000). However, even these bidimensional scales were createdfor specific groups (e.g., the VIA was designed for the Chinesesub-Asian population). More importantly, although the bidi-mensional scales, such as the revised SL-ASIA (Suinn et al.,

1995), result in two scores, there is no way to integrate thesetwo scores except to treat each as independent from the other.Additionally, the bidimensional scales are more accurate, but

the two resulting scores make for more involved analyses, asmost runs will need to be conducted independently based oneach acculturation score. Similarly, this issue is evident in inte-

grative studies such as meta-analytic studies similar to this one.The fact remains that numerous steps have been taken to

attempt to address the various shortcomings associated withthe development and application of acculturation scales.

Despite these various negative aspects, the utility of accultura-tion measures remains prominent in the literature and henceprovides the basis for this meta-analysis. However, there are

question marks in the literature with regard to the fragmentedresults of the effects of acculturation on health outcomes.Despite the popularity of these acculturation scales and the

desire to capture the effects of the process of acculturation onindividuals and their health, it is evident that these accultura-tion scales need to be applied with caution and attention to

other demographic and contextual factors of the populationsbeing studied. This is especially the case when extreme variabil-ity exists in the population sample, such as is the case oftenassociated with Asian Americans.

Heterogeneity, Contextual Factors, andAcculturation

The modeling of acculturation on a presumed homogenous

assumption of the population ignores the immense diversitythat exists and concurrently obscures both conceptual andmethodological issues that could arise (Hunt et al., 2004). In

other words, more differences than similarities exist in theseAsian American studies that group the various Asian sub-

groups together and therefore ignore the contextual issues thatarise because of social, cultural, and historical confounds. Huntet al. (2004) argued that inferences from observed correlations

in such studies actually indicate an insidious acceptance ofcultural stereotypes. Therefore, it becomes imperative that, asresearchers, we account for issues related to contextual factors

such as historical origins, immigration situations, and socioeco-nomic statuses (SES) that could help explain the results ratherthan attributing them to acculturation. This further highlights

the importance of conducting this meta-analytic study, wherebythe impact of the inclusion or exclusion of contextual factorsand within-group differences among the various acculturationstudies in the literature can be calculated and synthesized. In

addition, a meta-analytic study allows for the comparison ofthe relationship between acculturation and depression as mea-sured in single Asian subgroup samples versus heterogeneous

Asian subgroup samples in an effort to gain a better under-standing of how this relationship differs when this variance isaccounted for.

Depression

To synthesize the studies associated with scaled acculturationmeasures, we decided to look at those studies that investigated

depression as an outcome. We picked depression because,regardless of ethnicity, depression is a serious mental healthproblem and is one of the leading causes of disability in theUnited States (Mathers & Loncar, 2006; Young, Fang, &

Zisook, 2010). In fact, the lifetime prevalence rate of depressionin the United States is about 16%, and among these only about21% seek treatment (Kessler et al., 2003). Depression may have

fatal consequences, especially for young individuals, because itis often underdiagnosed and undertreated (Young et al., 2010)and is linked to increased risk for suicide (Zisook et al., 2009).

However, it is insufficient to describe the process and outcomesof depression among ethnic groups without examining the influ-ence of cultural factors on this outcome that has both acuteand chronic health implications. In other words, the cultural

conditions under which certain ethnic groups are at risk ofdeveloping depression become important. One of the mostextensively researched cultural factors among Asian Americans

is acculturation, but the findings remain conflicted and diver-gent (Hwang & Ting, 2008). This provides the rationale forinvestigating the impact of an important cultural variable such

as acculturation on depression.Contrary to the model minority myth, the literature has sug-

gested that Asian Americans experience mental health issues

equivalent to, if not greater than, other ethnic groups (Uba,1994). For example, lifetime prevalence of major depression is17.9% for non-Hispanic Whites, 10.8% for non-HispanicBlacks (Breslau et al., 2006), and 17.3% for Asian Americans

(Takeuchi et al., 2007). Both community and college studentpopulations report high levels of depression and anxiety(Okazaki, 1997). For instance, refugees from Southeast Asia

show a greater probability of suffering from mental healthproblems such as posttraumatic stress disorder related to thecircumstances of their immigration (Mui, 2001). Yeung et al.

(2004) reported that 20% of Chinese Americans were found tohave major depressive disorders, which was comparable to or

374 GUPTA, LEONG, VALENTINE, AND CANADA

even higher than that reported by nonminority ethnic groups inAmerica. Lai (2004) reported that 23% of the elderly immi-grants from Mainland China to Canada were found to suffer

from depressive symptoms. Similar results were found withother Asian subgroups (such as Korean, Indian, Filipino,Vietnamese, and Japanese), among whom 40% reported depres-

sion (Mui & Suk-Young, 2006; Otsuki, 2003). These data indi-cate that Asian Americans show high prevalence rates fordepression and depressive symptoms.

When the prevalence rates of depression were examinedwithin the context of acculturation, mixed results were obtained(Young et al., 2010). For example, in samples of minimallyassimilated Asian Americans, the reported depression rates

were lower compared with Caucasian students (Carmody, 2005;Takeuchi et al., 1998). Other studies reported the opposite,whereby less assimilated Asian Americans reported the preva-

lence of higher depression rates (Hasin, Goodwin, Stinson, &Grant, 2005; Kuo, Chong, & Joseph, 2008; Okazaki, 1997).Over the past eight decades, more than 200 measures have

been developed to assess the severity of depression (Santor, Gre-gus, & Welch, 2006). An analysis of these measures indicated thatthe depression measures differed in content, response format,

and objectives. Despite the variability across measures, the con-tent of the items in the various measures was similar with fewconsistent differences, with an exception in the followingdomains: anxiousness, suicidality, and loss of interest. Often con-

structs such as depression, sadness, worthlessness, and socialwithdrawal were assessed in the depression measures. Despite theplethora of depression scales that has been developed since 1918,

only a few are consistently used. In addition, the literature dem-onstrates that depression scales are more frequently used in treat-ment outcome studies of depression versus basic science studies.

The depression scales consistently used in treatment outcomestudies were mainly developed more than 20 years ago andinclude the following: Beck Depression Inventory, Center for Ep-idemiologic Studies-Depression, Hamilton Rating Scale for

Depression, and Symptom Checklist 90-Depression (SCL90-D).It should be noted that measuring depression among Asians

presents additional challenges. Among these are the concerns

that depression is usually conceptualized from a WesternEuropean framework but may manifest itself at least somewhatdifferently in other cultures. Further, it may be the case that

Asians are less likely to endorse depression items than arepeople of Western European descent, even if these groups actu-ally experience similar levels of depression (Wong, Tran, Kim,

Kerne, & Calfa, 2010). If true, both of these concerns wouldmake depression somewhat harder to detect among Asians andwould result in an attenuation (i.e., a biased underestimate) ofthe relationship between depression and acculturation in Asian

samples. Our current meta-analysis will interpret the findingswithin the context of these points because our analyses arebased on data in the literature that is limited by the scales and

analyses conducted by the original authors.

Rationale and Hypotheses for the Study

A comprehensive review of the literature demonstrates that

there are divergent and conflicting findings regarding the effectsof acculturation on depression. In other words, there is no clear

consensus about the outcomes and influence of acculturation.This could be because the two-dimensional theory and modelproposed by Berry (1980) suggests that high acculturation is

associated with positive health outcomes and low acculturationwith negative health outcomes and behaviors. However, the lit-erature sometimes associates high acculturation with positive,

and at other times with negative, health outcomes. Clearly,there are inconclusive hypotheses regarding the directional rela-tionship between acculturation and well-being (Das & Kemp,

1997; Hall & Okazaki, 2002; Lau, Jernewall, Zane, & Meyers,2002; Sue, 1994). This meta-analysis will help synthesize andsummarize the direction and magnitude of the relationshipbetween acculturation and depression among Asian Americans.

The relationships between acculturation and depression willbe analyzed and interpreted with attention to the following: (a)type of acculturation measure (e.g., SL-ASIA vs. other), (b)

type of Asian subgroup (e.g., Chinese, Indian), and (c) contex-tual factors (e.g., immigration status, age).

Hypothesis 1: We hypothesize that both high orientation to the

U.S. culture (assimilation) and high orientation to the Asian cul-

ture (separated) will be associated with less depression. This sug-

gests that associating with any culture is positive and has both

practical advantages and preferential utility.

Hypothesis 2: A correlation will be conducted to test the relation-

ship between orientation to U.S. culture and orientation toward

Asian culture. This has implications for better understanding the

unidimensional versus the bidimensional acculturation models. This

is because the unidimensional model of acculturation posits that

the two cultural identities are inversely related (i.e., orientation to

U.S. culture on one end of the continuum and orientation to Asian

culture on the other end), whereas the bidimensional acculturation

model is based on the theory that the two modes of acculturation

(orientation to U.S. culture and orientation to Asian culture) are

actually not inversely related. Consistent with the newer and

revised theory on acculturation, we propose that these data will

show evidence for the bidimensional acculturation model, provid-

ing further evidence for the validity and utility of the bidimensional

model.

Hypothesis 3: We also believe that because of the extreme heteroge-

neity that exists within ethnic groups, studies that investigate single

sub-Asian groups versus multi-Asian subgroups will demonstrate

stronger effect sizes between acculturation and depression. Ideally,

we would have liked to have analyzed the data for Asian cultures

separately (e.g., China vs. Japan vs. India) and also based on con-

textual factors such as immigration status, generation status, and

so forth, but because of the small number of studies in each cate-

gory (attributable in part to the lack of consistency in providing

such details), we were unable to investigate these factors.

Hypothesis 4: As the SL-ASIA is one of the most widely used and

accepted acculturation measures used among Asian Americans, we

propose to explore the effects sizes of studies that use the SL-ASIA

(Suinn et al., 1987) acculturation scale versus other acculturation

measures. Ideally, we would also propose to compare the unidi-

mensional SL-ASIA (Suinn et al., 1987) with the bidimensional

SL-ASIA (Suinn et al., 1992), but because of the limited number

of studies present (there was only one study that used the bidimen-

sional SL-ASIA, Oh, Koeske, & Sales, 2002), this comparative

analysis was not possible.


Method

Systematizing and exploring themes across the vast majorityof cultural studies and data currently present are extremely dif-

ficult (Van Hemert, 2003). Van Hemert suggests conductingmeta-analyses as a way of integrating and synthesizing culturalstudies. Meta-analytic studies that deal with cultural data can

be conducted in one of two ways: (a) one that involves compar-isons across one instrument (e.g., using only studies that usedthe SL-ASIA), or (b) the other that involves domain-basedinvestigations that involve culture-specific information (e.g., ori-

entation to U.S. culture vs. orientation to Asian culture). Inthis study, we used the second method because of the diversemethods of quantifying, labeling, and operationalizing con-

structs like acculturation and depression. Meta-analysis tech-niques were used in this study as an attempt to synthesize therelevant findings and address the question of how acculturation

as measured by scales is related to depression among AsianAmericans. These analyses are also used to direct futureresearch efforts in this area.

Search Strategy, Retrieval of Studies, InclusionCriterion

To obtain a comprehensive sample consisting of both pub-lished and unpublished studies on acculturation and depression

among Asian Americans, several electronic databases weresearched: PsychInfo, EBSCOhost, Medline, Academic SearchPremier, Anthropological Plus, Web of Science, Sociological

Abstracts, Social Work Abstracts, and ProQuest Digital Dis-sertations. The keywords used were identified using searchengine thesauruses and dictionaries as well as our own exper-

tise in this area. The keywords were intentionally broad to beas inclusive as possible. Generally, we searched for terms sug-gesting that Asians were in the sample (Asia*) and that accul-

turation (e.g., acculturation or assimilation), and well-being(e.g., depression, distress, or isolation) were measured. We useda series of categories, connecting terms within categories by anor statement and across categories by an and statement. See

Table 2 for a full description of the keywords used in thesearches. Because of the arbitrary nature of such decisions, we

did not set a lower limit on the publication date for studyinclusion.

Sample and Coding Procedure

Our initial search yielded 2,613 studies. Titles and abstractswere read to determine whether studies (a) were quantitative,(b) involved Asians or Asian Americans, (c) noted that the

Asians or Asian Americans were living in North America, and(d) measured acculturation. Studies that clearly did not meetthese criteria were excluded. Judgments were made indepen-

dently by at least two of the authors. After disagreements wereresolved (which occurred via consensus), 747 studies appearedto be potentially eligible for inclusion. The full text of thesestudies was obtained, and on the basis of information in the

studies, we categorized the nature of the acculturationmeasurement into two categories: Most (550) measured accul-turation using a proxy measure, and 197 used a scale (e.g., the

SL-ASIA). This analysis focuses on the studies that used scaledmeasures. We then selected the studies that assessed depressionfrom within the broad construct of well-being, and this

resulted in 38 studies. The 38 studies were coded on variousdemographic and psychometric properties (e.g., age, gender,Asian subgroup, immigration status, socioeconomic status,

measure reliabilities, and validities). For studies for which wecould not obtain all necessary data, we contacted the authorsfor additional information and received responses from allauthors contacted. To avoid violations of the assumption of

statistical independence, studies that gave multiple estimates ofthe acculturation–depression relationship on the same sample(e.g., more than one depression measure, or measured depres-

sion at more than one point in time) were averaged to arriveat a single, composite effect size (Cooper, 1998; Cooper &Hedges, 1994).

Because we were interested in the relationship between accul-turation and depression, results are reported in terms of corre-lation coefficients. Some studies provided estimates in othermetrics (e.g., a t-test), and in these cases, we converted the

reported statistics into correlation coefficients (Lipsey & Wis-lon, 2001). Meta-analyses were conducted using the Compre-hensive Meta-Analysis software (Borenstein & Rothstein, 1999).

Because most of the studies in our review assessed accultura-tion using a unidimensional measure that provided one scoreand because the few studies that used bidimensional models

provided two independent scores, we were able to conduct twomain meta-analyses. The first of these assessed the relationshipbetween depression and orientation to U.S. culture (assimila-

tion), and the second assessed the relationship between depres-sion and orientation to Asian culture (separated; see Table 1).In addition, because we were able to calculate effect sizes forboth dimensions of acculturation, we were also able to test the

assumption that orientation to U.S. culture and orientation toAsian culture are negatively related.

Model Applied

Meta-analysts need to consider whether to employ a fixedeffect or a random effects analytic model. When the fixed effectmodel is used, study effect sizes can be thought of as estimating

Table 2. Search Terms and Categories

Search

categories Search terms

Asian Asia*Acculturation Acculturation, assimilation, cultural assimilation,

culture change, cross-culture communication,

marginalization, cultural sensitivity,

cross-cultural psychology, multiculturalism

Well-being

(Depression)

Accommodation, achievement, adaption,

adjustment, agitation, cope, depression,

distress, emotional states, failure, health,

isolation, loneliness, mental health,

physical comfort, physical health, sadness,

separation, stress, suffering, well-being


a single population value, and, therefore, any differences ineffect sizes across studies are treated as solely because of ran-dom sampling and identifiable covariates. Using the random

effects model, reviewers assume that studies do not in fact sharea single population value but instead come from a distributionof effect sizes. Therefore, any differences in effect sizes across

studies are because of random sampling error, any identifiablecovariates, and other random factors that cannot be identified.The choice between fixed effect and random effects models

can be an important one, because the confidence intervals aris-ing from a random effects analysis will never be smaller andare often larger than their fixed effect counterparts; this hasimplications for both the statistical significance tests and inter-

preting the likely range of population effects. For this review,we chose the random effects model, in part because of the rela-tively wide variability in the samples and measures used in the

studies and also because we were interested in the somewhatbetter generalization properties of this model relative to thefixed effect model (Hedges & Vevea, 1998).

Results

The 38 studies used are presented in the reference list anddenoted with an asterisk. Two tables (Tables 3 and 4) are

shown depending upon the acculturation type (orientation toU.S. culture and orientation to Asian culture)—Hypothesis 1.Information on the author, study type or class, study samplesize, effect size, Asian subgroup sample, and details regarding

acculturation and depression measures are included. Figure 1presents a forest plot that summarizes the effect sizes and largesample confidence intervals for studies assessing orientation to

U.S. culture. There were only a few studies that revealed statis-tically significant effect sizes (i.e., those effect sizes whose 95%confidence intervals did not cross the zero line on either side),

and most effect sizes cluster around the mean. That said, therewas considerable variability among individual studies, Q(32)= 173.640, p < .001, I2 = 82.000. The overall weighted averageeffect size was r = �.068 (95% CI = �0.117 to �0.018,

p = .007). On the basis of the suggestions offered by Valentine,Pigott, and Rothstein (2010), we found that, on the basis of thenumber of studies we obtained, our power to detect an effect

with a small correlation coefficient of r = .10 was high (>.90).Figure 2 is a forest plot that summarizes the effect sizes and

large sample confidence intervals for the studies assessing orien-

tation to Asian culture. Again, there were only a few studiesthat showed significant effect sizes (i.e., those effect sizes whose95% confidence intervals did not cross the zero line on either

side), and most studies clustered around the mean. There wasconsiderable variation among individual studies, Q(13)= 64.157, p = .000, I2 = 79.737. The weighted average effectssize was r = �.021 (95% CI = �0.099 to 0.058, p = .603). For

these scales, post hoc power analysis to detect a small degree ofrelationship (r = .10) was not as high, but was still good at anestimate of .76.

To examine Hypothesis 2 (i.e., the relationship between thetwo acculturation modes), we calculated the correlationbetween orientation to the U.S. culture and orientation to the

Asian culture. The correlation between the effect sizes from theorientation to U.S. culture group versus the orientation to

Asian culture was small and not statistically significant, �.055(95% CI = �.277 to .172, p = .636). There was also consider-able variation among individual studies, Q(7) = 181.637,

p = .000, I2 = 96.146.

Moderator Tests

Hypothesis 3—sample composition. Study sample(i.e., multiple subethnic groups vs. single ethnic subgroups) wasanalyzed as a categorical moderator. Given the theoretical con-

siderations outlined earlier, we would have liked to have exam-ined separate Asian subgroups separately. However, there weretoo few studies in most categories to support this analysis.

There were, however, 13 studies that used multiethnic groupsamples and 20 studies that used single subethnic group sam-ples. We therefore conducted an analysis comparing the studies

that used multiple and heterogeneous ethnic samples with thosestudies that used single ethnic group samples on the mean effectsizes among these studies. The mean effect sizes ranged from�.091 (95% CI = �.161 to �.020, p = .012; heterogeneous sub-

ethnic group sampling) to r = �.055 (95% CI = �.118 to .009,p = .091; single ethnic subgroup samples); these groups werenot statistically significantly different from one another, Q(1)

= .56, p = .45, suggesting that studies using single ethnicgroups yielded effect sizes that were similar to those studiesthat used heterogeneous ethnic group samples. Unfortunately,

the studies in this review did not consistently report samplecharacteristics, such as SES (reported by 20% of studies), nativ-ity (8%), immigration status (20%), and generation status

(10%), and as such we were unable to assess the effects of thesecontextual factors on the relationship between acculturationand depression.

Hypothesis 4—acculturation scale type. An explor-atory analysis was conducted to determine the strength of the

effect sizes of the SL-ASIA scale in comparison with studiesthat used other acculturation scales. For the orientation towardU.S. culture, there were 13 studies that used the SL-ASIA and20 studies that used another type of acculturation measure.

The mean effect sizes ranged from r = �.089 (95% CI = �.149to �.028, p = .0004; SL-ASIA scale) to r = �.056 (95%CI = �.121 to .010, p = .097; all other acculturation scales).

Again, these were not statistically significantly different fromone another, Q(1) = .528, p = .467. Because this test was alsononsignificant, the results suggest that scale type does not seem

to matter in that studies that used the SL-ASIA were similar tostudies that used the other acculturation scales. Because therewas only one study (Oh et al., 2002) that used the revised bidi-

mensional SL-ASIA versus the unidimensional SL-ASIA, wewere unable to directly make a comparison between the twotypes of acculturation models to be able to make concretestatements regarding the superiority of one model over the

other.

Follow-up Analysis

We conducted two follow-up analyses to check for (a) overly

influential studies and (b) the possibility of publication bias.


Table 3. Summary Statistics for American Assimilation

Author Sample size (N) Effect size (ez) Acculturation measure Depression measure Asian subgroup

Ayers 591 �.119 SL-ASIA CES-D Korean

Casado 150 �.261 ASSA-LSF CDS-16 Chinese

Chen 120 .203 SL-ASIA CES-D Chinese, Japanese

Choi 178 .225 VIA CES-D Korean

Chu 179 .100 SL-ASIA CES-D Chinese, Filipino, Japanese,

Vietnamese, Korean,

Cambodian/Khmer,

Laotian, Hmong, Indian,

Biracial, Other

Crane 41 �.300 SL-ASIA CDI-S Chinese, Taiwanese,

Taiwanese

Dinh 124 .020 SL-ASIA CES-D Chinese, Vietnamese,

Korean, Other

Ebreo 124 .005 AS CES-D Unknown

Go 206 �.003 SL-ASIA CES-D Chinese, Vietnamese,

Cambodian/Khmer,

Laotian, Hmong, Other

Gonzales 59 �.020 SL-ASIA CES-D Filipino

Hung 306 �.143 SL-ASIA CES-D Chinese, Filipino, Korean,

Taiwanese

Hwang and Ting (2008)a 107 �.210 VIA HDI Chinese, Japanese,

Vietnamese, Korean,

Taiwanese

Hwang and Myers (2007) 1,747 .060 Burnam Scale UM-CIDI Chinese

Jang and Chiriboga (2010)a 472 �.230 Jang Scale GDS-SF Korean

Jang et al. (2009) (younger cohort) 209 �.110 Jang Scale CES-D Korean

Jang et al. (2009) (older cohort) 462 �.200 Jang Scale CES-D Korean

Juanga 309 �.067 AS CES-D Chinese

Kheraa 1,212 �.062 MAS CES-D Indian

Kim (2008)a

294 �.230 AAMAS-EA CES-D Chinese, Korean

Kim (2009)a

78 .130 AAS CES-D Korean

Kim (2007) 51 �.196 SL-ASIA GDS Korean

Lam 45 .387 Anderson Scale GDS Chinese

Lim 51 �.220 AAMAS BSI-18 Korean

Nguyena 182 �.260 ASVA CES-D Vietnamese

Oha,b 157 �.230 SL-ASIA CES-D Korean

Periyanayagam 355 .273 CAAS CES-D Indian

Shen 983 .030 AS SCL-90R Chinese

Skinner 109 �.110 SL-ASIA CDI Chinese

Soriano 100 �.040 SL-ASIA BDI-II Chinese, Filipino, Japanese,

Vietnamese, Korean,

Pakistani

Tahseen 27 �.220 EAVS-AA-R BDI-II Chinese, Korean

Takebayashia 101 �.100 GAF -SCL-90R-DEP Chinese, Filipino, Japanese,

Vietnamese, Korean,

Thai, Indian, Other

Yasuda 63 �.180 SL-ASIA D-HS Chinese, Filipino, Japanese,

Vietnamese, Korean,

Thai, Indian, Other

Random 10,939 �.068 �.117/�.018 �2.679 .007

Note. Acculturation measures: SL-ASIA, Suinn-Lew Asian Self-Identity Acculturation Scale; ASVS-AA-R, Asian Values Scale; AS, Acculturation

Scale; CAAS, Canadian Acculturative Attitudes Scale; ASVA, Acculturation Scale for Vietnamese Adolescents; ARSMA, Acculturation Rating Scale

for Mexican Americans; AAMAS, Asian American Multidimensional Acculturation Scale; MAS, Multi-group Acculturation Scale; VIA, Vancouver

Index of Acculturation; ASSA-LSF, Acculturation Scale for Southeast Asians; CES-D, Depression measures: Center for Epidemiological Studies-

Depression; SCL-90R-DEP, Symptom Checklist; BDI-II, Beck Depression Inventory; CDI, Children’s Depression Inventory; BSI-18, Brief Symptom

Inventory; GDS, Geriatric Depression Scale; HDI, Hamilton Depression Inventory; UM-CIDI, Depression Module of the Composite International

Diagnostic Interview; CDS-16, Children’s Depression Scale.aStudies that measured acculturation both as orientation to the U.S. culture and orientation to the Asian culture (N = 9). bStudy that used the

SL-ASIA 1992 version (bidimensional model; Oh et al., 2002).


First, we reran the meta-analyses removing one study at a time.This procedure assists with the identification of potentiallyinfluential studies that might be driving study conclusions. Inthis case, however, there were no substantive or statistically

conclusive changes to the effects observed when studies wereindividually removed and the analyses rerun. The next sensitiv-ity analysis involved carrying out a trim and fill analysis (Duval

& Tweedie, 2000) as a check on the possibility of publicationbias. Publication bias is the tendency for studies lacking statisti-cally significant outcomes to be less likely to be published and

results in a bias against the null hypothesis. If publication biasdoes occur, then one way it will reveal itself is as a negativecorrelation between a study’s effect size and its sample size. To

illustrate, imagine two studies with the same small sample sizewith one rejecting the null hypothesis and one that does not. Itwill likely be easier for the study with statistically significantresults to get published; in a body of literature, this process will

result in a negative correlation between sample size and effectsize in the published literature (small samples will have largereffects). The trim and fill analysis essentially examines the distri-

bution of effect sizes, trims (i.e., drops) studies until an approx-imately normal distribution of effect sizes is left, and fills (i.e.,adds in) effect sizes for studies that appear to be missing. This

procedure did not reveal any potential problems associatedwith publication bias. Specifically, the follow-up analysisrevealed that the new effect sizes were very similar to the oldeffect sizes. Many of our unpublished studies included disserta-

tions, and the proportion of unpublished studies including dis-sertations in our sample was 36.8%.

Discussion

Relationship Between Acculturation andDepression

Whereas most theorists believe that acculturation, or rather alack of acculturation, is a contributor to depression, our results

suggest that a more nuanced view in line with more modernconceptualizations of acculturation is warranted. Most modernacculturation theorists (e.g., Hunt et al., 2004) believe that it isa multidimensional construct and, unlike earlier theorists (e.g.,

Berry, 1980), believe that it is possible for individuals to beacculturated in more than one society. However, this thinkinghas not yet permeated the literature examining the association

between acculturation and depression. Generally, we found thatstudies examined either orientation to American culture (32studies) or orientation to Asian culture (15 studies); few (nine

studies) examined both orientations. The meta-analyses revealsthat when acculturation is measured as assimilation to the newculture (i.e., orientation to U.S. culture), there is a small butstatistically significant negative relationship between the degree

of acculturation and scores on measures of depression (i.e.,higher acculturation is associated with less depression). Whenacculturation is measured as adherence to the traditional cul-

ture (i.e., orientation to Asian culture), there is also a small,negative relationship observed, but this is not statistically sig-nificant. These effect sizes suggest that orientation toward any

culture is a positive concept, and, hence, the correlation ofacculturation with a negative health outcome decreases. These

Table 4. Summary Statistics for Separated/Adherence to Asian Culture

Author Sample size (N) Effect size (ez) Acculturation measure Depression measure Asian subgroup

Benner 444 .135 VIA CES-D Chinese

Davis Men 197 .120 SL-ASIA CES-D Chinese

Davis Women 197 �.240 SL-ASIA CES-D Chinese

Foss 30 �.400 SL-ASIA HSCL-25 Vietnamese, Hmong

Hwanga 107 .020 VIA HDI Chinese, Japanese,

Vietnamese,

Taiwanese

Janga 452 �.130 Jang Scale CES-D Korean

Juanga 309 �.087 AS CES-D Chinese

Kheraa 1,212 �.017 MAS CES-D Indian

Kim (2008)a 294 .140 AAMAS-CO CES-D Chinese, Korean

Kim (2009)a 78 .330 AAS CES-D Korean

Nguyen et al. (1999)a 182 .120 ASVA CES-D Vietnamese

Nguyen and Peterson (1993) 50 �.290 AS TDI Vietnamese

Oha,b 157 �.170 SL-ASIA CES-D Korean

Patel 142 �.080 MMRS DASS South Asian

Takebayashia 101 .600 AIF SCL-90R-DEP Chinese, Filipino, Japanese,

Vietnamese, Korean, Thai,

Indian, Other

Random 3,851 �.021 �.099/.058

Note. Acculturation measures: SL-ASIA, Suinn-Lew Asian Self-Identity Acculturation Scale; AS, Acculturation Scale; ASVA, Acculturation Scale

for Vietnamese Adolescents; AAMAS, Asian American Multidimensional Acculturation Scale; MAS, Multi-group Acculturation Scale; VIA, Van-

couver Index of Acculturation; MMRS, Majority-Minority Relations Survey. Depression scales: TDI, Thai Depression Inventory; DASS, Depression

Anxiety Stress Scales; HSCL-25, Hopkins Symptom Check List; CES-D, Center for Epidemiological Studies-Depression; SCL-90R-DEP, Symptom

Checklist.aStudies that measured acculturation both as orientation to the U.S. culture and orientation to the Asian culture (N = 9). bStudy that used the

SL-ASIA 1992 version (bidimensional model; Oh et al., 2002).


results align with the literature related to ethnic identity, sug-gesting that the ability to identify with a specific culture acts asa protective factor and hence buffers against negative healthoutcomes.

The results are significant for the orientation toward U.S.culture but not in the orientation toward Asian culture. Thiscould be because of the small number of studies and smaller

sample sizes in the second group analysis compared with thefirst group. More importantly, the results could reflect the rela-tionship between assimilation to the United States and depres-

sion as an outcome of cultural congruence (Leong &Kalibatseva, 2011). In other words, when immigrants movetoward becoming more congruent with the dominant culture,

they experience lower levels of depression but in a complexfashion as reflected in this meta-analysis. This could be becauseof the difficulties researchers face in accurately operationalizingand measuring acculturation or that acculturation relates to

mental health outcomes in a complex fashion. These two

possible explanations are probably also what accounts for themodest relationships we found in this meta-analysis. Clearly,these are possibilities that need further exploration and valida-tion.

Implications for Conceptualization andMeasurement of Acculturation

Based on the unidimensional acculturation model, much of

the research literature has conceptualized orientation towardU.S. culture and orientation toward Asian culture as two oppo-site and negatively related concepts. However, we failed to find

any evidence of even a modestly strong negative relationshipbetween mainstream acculturation and traditional adherencewhen studies measured both dimensions on the same sample.

Our results revealed a small, nonsignificant negative correlation,with confidence intervals that ranged from a moderately strongnegative effect to a moderately strong positive effect. This is

Figure 1. Effect sizes for the relationship between U.S. assimilation and depression.


perhaps the most important empirical result arising from our

work. Although it is clear that theorists have been movingaway from the unidimensional conceptualization of accultura-tion, many researchers (at least implicitly) continue to endorsethis simplistic model. We hope that this work will lead to a

reduction in the use of unidimensional measures of accultura-tion. The bottom line is that although we were not able todirectly compare the unidimensional scales with the bidimen-

sional scales in order to provide some evidence of the superior-ity of the later model, we were able to indirectly provideevidence that the two modes of acculturation are not inversely

correlated, which has been postulated as the basis for bidimen-sional models. Hence, there is some support suggested for theutility and importance of using bidimensional acculturationmeasures in our future research endeavors.

The literature on acculturation has also suggested that mea-suring heterogeneous groups ignores the tremendous amount ofwithin-group variability that exists in these populations. This

has been the impetus in the field to move toward investigatingmore homogeneous ethnic groups to make more concrete con-clusions about our research. The difficulties of evaluating cul-

tural factors within the context of individual personality andsituational circumstances are exacerbated when issues of diver-sity and heterogeneity are ignored. Ideally, to directly test for

the effects of these contextual factors, we would have preferredto run additional analyses, but because of the limited andinconsistent data available across studies, we were unable to doso. However, to examine this theory further, we compared the

effect sizes from studies that examined single ethnic groups withthe effect sizes from those studies that investigated multiple eth-nic subgroups. Our data did not support the hypothesis that

single ethnic group studies would have bigger effect sizes thanmultiple ethnic group studies. This result should be considered

tentative, however, because of the limited way that the dataforced us to operationalize the heterogeneity of the Asians inthe sample (i.e., a simple cut of one Asian subgroup vs. more

than one Asian subgroup). We hope that future investigationswill result in a more nuanced treatment of both the heterogene-ity of Asian groups and the relationship between acculturation

and depression among specific Asian groups.The SL-ASIA (Suinn et al., 1987) has been a widely accepted

and used acculturation scale in the field. As a result, we wanted

to explore the strength of the effect sizes of the SL-ASIA scale incomparison with studies that used other acculturation scales toprovide justification for the popularity of the utility of this scale.Our analyses indicated that studies using the SL-ASIA scale had

stronger effect sizes than the studies that used another accultura-tion scaled measure. Ideally, we would have liked to compare theearlier version of the SL-ASIA (1987), which is based on the un-

idimensinal model, to the revised version of the SL-ASIA (1992),which is based on the bidimensional model. This would have alsohelped us provide further direct evidence of the strength of the

bidimensional model over the unidimensional one. However, inour pooled sample of studies, we found only one study (Oh et al.,2002) that used the revised bidimensional SL-ASIA scale. This

highlights a concern that, although the bidimensional model hasbeen proposed as the preferred and improved acculturationmodel, researchers are still using the older models, as evidencedby the greater utility of the older version of the SL-ASIA scale in

our sample of studies.

Implications for Depression Among AsiansLiving in North America

Our results revealed a small, negative relationship betweenthe degree of acculturation and scores on a depression inven-tory. It should be noted that the relationship was not statisti-

cally significant for studies that measured the degree oforientation to the Asian culture. In fact, the estimates arisingfrom studies measuring acculturation as orientation to theAsian culture and those measuring acculturation as orientation

to the U.S. culture were not statistically significantly differentfrom one another. As such, to illustrate the potential meaning-fulness of this relationship, assume that the actual relationship

between the degree of acculturation and scores on a depressioninventory is r = �.055 (approximately the weighted mean ofthe two analyses). This continuous correlation can be approxi-

mately translated to an odds ratio of 1.20. In other words, theodds of a relatively unacculturated individual being depressedare 1.20 times greater than the odds of a relatively well-accul-

turated person being depressed. Put somewhat differently,imagine a large study of Asians living in North America, 15%of whom are depressed. The depression risk for relatively unac-culturated individual would be about 1.03 times greater than

the depression risk for relatively acculturated individuals.Another way of expressing this effect is to say that for every 42relatively acculturated individuals with depression, there will be

43 relatively unacculturated depressed persons.Clearly, this is a small effect. Two points seem to merit dis-

cussion, however. First, at the population level, effects even as

small as this can translate into large numbers of additionaldepressed individuals. From a public health standpoint, it does

Figure 2. Effect sizes for the relationship between orientation to Asian

culture and depression.


not seem prudent to simply dismiss these effects out of hand.Perhaps more important, we have already elaborated on theempirical evidence from this study that acculturation was not

measured well in the studies in this review. Recall also thatresearchers measuring depression in Asian samples face chal-lenges as well. Among these are the potential for incompletely

measuring the construct of depression as it manifests itself inAsians and the possibility that Asians may underreport depres-sion symptoms. However, we cannot test for these measurement

difficulties unless researchers use depression scales designed spe-cifically for Asian Americans. More importantly, we were notable to conduct any analyses that accounted for contextual fac-tors such as immigration status or generation status. The litera-

ture points to the importance of considering these variouscultural factors, but unless researchers measure and report thesefactors consistently across studies, group comparisons become

difficult and meaningless. All of these concerns suggest that ourestimate of the relationship between acculturation and depres-sion represents a lower-bound estimate, and better measure-

ment of the constructs (acculturation and depression) mightreveal a stronger relationship.

Conclusion

Whereas researchers have come to recognize the importantrole that acculturation plays in the understanding of the experi-ence of Asian Americans, the current study provides a system-atic examination of the relationship between scaled measures of

acculturation and depression in the existing set of studies. Twogroups of studies were analyzed: those measuring orientation tothe U.S. culture and those measuring orientation to the Asian

culture. Our results highlight that acculturation is a complexprocess. This complexity is represented by two related but sepa-rate areas of research, which we have sought to compare in the

same analysis. From our results, we can summarize that accul-turation and depression are related, but in a more complexfashion than we had assumed or hoped for in the past. In addi-tion, this relationship varies by type of acculturation (i.e., ori-

entation to U.S. culture and orientation to Asian culture). Thiscomplexity calls for considerable caution regarding the impactof acculturation on depression among Asian Americans. We

hope that future investigations will provide a clearer pictureand understanding of this relationship. Additionally, as furtherdata become available, more accurate analyses and compari-

sons will become possible.To summarize, we believe that acculturation has and will

continue to be an important variable in the cross-cultural litera-

ture. However, to get accurate and meaningful data, we need tofacilitate the following steps:

• Greater use of the bidimensional acculturation models.

• Development and use of depression scales specific for

Asian Americans that are based on a more accurate defini-tion of acculturation. The bigger issue is that we first needto define and measure acculturation in a way that captures

its dynamic and multidimensional aspects versus treating itas a trait or characteristic.

• Consistent measurement and reporting of contextual fac-

tors (e.g., immigration status, generation status, SES)

across studies to account for the variance we see in studysamples. We advocate greater use of contextual factors instudy models and analyses to explain the results versus as

a way to describe the sample in detail. We also need toaccount for the variance in our results that is because ofthe heterogeneity of our sample (e.g., Asian subgroup

breakdowns). Again, this will be more meaningful.

• Lastly, we need to refrain from defining acculturation ascultural congruence. This only reinforces the cultural

stereotypes that are present and pathologizes those who donot meet those stereotypes or ostracizes those who do notcomply with the practices of the group.

It is evident that more data are needed, and with thisincrease in information, these relationships will become clearer.

However, these data from this study provide strong evidencefor future research directions.

Keywords: Asian Americans; acculturation; depression; assimi-lation; immigration status; generation status; orientation to cul-

ture; ethnic identity; acculturation measure; bidimensionalacculturation model

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N.B. Studies marked with an asterisk are the studies that were

included in the meta-analyses.

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A meta‐analytic study: The relationship between acculturation and depression among Asian Americans