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The effects of acculturation on psychological stress measures in young Middle Eastern American adults

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The effects of acculturation on psychological stress measures in young Middle Eastern American adults
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Wilson, Meredith ( author )
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Acculturation ( lcsh )
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Acculturation is the cultural adjustment that a group or individual experiences when previously separate cultures interact with one another. Understanding this process is important for immigrant and minority groups in the United States, who commonly navigate two or more distinct cultures. This research sought to understand how an individual’s acculturation trajectory, that is whether they are assimilated, integrated, separated, or marginalized, affected psychological measures. The acculturation trajectories, perceived stress, self-esteem, and discrimination in young adult first, second, and third generation Middle Eastern Americans who were living in the Denver metro area were studied. Online survey data on acculturation, perceived stress and self-esteem were collected from 43 adults (ages 18-35) who identified as Middle Eastern American. The results of the analysis suggest that acculturation trajectories vary across individuals, and these differences can have important impacts on perceived stress and other psychological outcomes. This research furthers our understanding of the impacts that acculturation can have on the mental health of migrant and minority individuals. These results will inform future studies and influence policies, like increasing community awareness of acculturation through educational programs that could improve the lives and health of immigrants and minorities in the United States.
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Thesis (M.A.)--University of Colorado Denver
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by Meredith Wilson.

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THE EFFECTS OF ACCULTURATION ON PSYCHOLOGICAL STRESS MEASURES
IN YOUNG MIDDLE EASTERN AMERICAN ADULTS
by
MEREDITH WILSON B.A., Dickinson College 2013
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Masters of Arts Anthropology Program
2017


This thesis for the Master of Arts degree by Meredith Wilson has been approved for the Anthropology Program by
David Tracer, Chair Zaneta M. Thayer, advisor
Sarah Horton


Wilson, Meredith (MA, Anthropology Program)
The Effects Of Acculturation On Psychological Stress Measures In Young Middle Eastern American Adults
Thesis directed by Professor David Tracer
ABSTRACT
Acculturation is the cultural adjustment that a group or individual experiences when previously separate cultures interact with one another. Understanding this process is important for immigrant and minority groups in the United States, who commonly navigate two or more distinct cultures. This research sought to understand how an individuals acculturation trajectory, that is whether they are assimilated, integrated, separated, or marginalized, affected psychological measures. The acculturation trajectories, perceived stress, self-esteem, and discrimination in young adult first, second, and third generation Middle Eastern Americans who were living in the Denver metro area were studied. Online survey data on acculturation, perceived stress and self-esteem were collected from 43 adults (ages 18-35) who identified as Middle Eastern American. The results of the analysis suggest that acculturation trajectories vary across individuals, and these differences can have important impacts on perceived stress and other psychological outcomes. This research furthers our understanding of the impacts that acculturation can have on the mental health of migrant and minority individuals. These results will inform future studies and influence policies, like increasing community awareness of acculturation through educational programs that could improve the lives and health of immigrants and minorities in the United States.
The form and content of this abstract are approved. I recommend its publication.
Approved: David Tracer
IV


ACKNOWLEDGEMENTS
This thesis has been approved by the COMIRB, protocol #16-099.


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION...................................................1
What Is Acculturation?.........................................1
The Context Of Acculturation For Young Middle Eastern
Americans......................................................3
Acculturation and Health.......................................6
Research Goals.................................................8
II. METHODS.......................................................10
Recruitment...................................................10
Participant Demographics......................................10
Survey Measures...............................................10
Statistical Analysis..........................................12
III. RESULTS.......................................................14
Summary Statistics Of Population Characteristics..............14
T-Tests Comparing Perceived Stress, Self-Esteem, Depression And
Discriminations For Integrated And Assimilated Groups.........15
Correlations Between Cultural Orientation Scores And Stress, Self-Esteem, Depression, And Discrimination................................16
IV. DISCUSSION....................................................17
REFERENCES................................................................25
APPENDIX..................................................................31
v


A. Online Survey
31
vi


LIST OF TABLES
TABLE
1. Summary statistics for population characteristics (standard deviations in
parentheses)....................................................................14
2. Summary statistics for population characteristics comparing integrated and
assimilated categories (standard deviations in parentheses).....................15
3. ANOVA results for comparing means of PSS, self-esteem, CESD-R, and EDS between integrated and assimilated
individuals.....................................................................15
4. Correlations table for cultural identity scores and stress, self-esteem, depression, and discrimination, controlling for religion, sex, financial status, generational status, and age
16


CHAPTER ONE
INTRODUCTION
An individuals health is influenced by many different factors, including their social and cultural environment. One such factor, which is of great interest in the public health research of minority groups in America, is the process of acculturation (Abraido-Lanza, et al. 2006). Research on acculturation is becoming more pertinent with the increase in globalization and cultural interactions in our society. Recently, acculturation has become of interest to public health researchers, as many recognize the possible effects acculturation can have on both individual and population health. One pathway through which acculturation may affect health is through increased levels of psychosocial stress (Berry, et al. 1987). Increased levels of psychosocial stress have been associated with increased prevalence of hypertension, cardiovascular disease and obesity (e.g. Mclnnis CM et al. 2014; Juster et al., 2010). As such, it is important for researchers to continue to study how acculturation and stress are related in order to better address health disparities.
1.1 What Is Acculturation?
The study of acculturation and its effects on individuals and groups is becoming increasingly important in our globalized society. Historically, the process of acculturation has been studied in anthropology (e.g. Boas, 1888; Redfield, et al. 1936) but more recently has become of interest to public health studies as acculturation may have significant effects on the health of minority populations (Abraido-Lanza, et al. 2006). Acculturation is the cultural adjustment or change that a group or individual experiences when previously separate cultures interact with one another and is a multidimensional process that can result in many different outcomes on the individual level (Berry 1997). Often, this occurs when a
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minority (migrant or indigenous) culture interacts with a majority (host or colonial) culture. I refer to the majority culture, in this study American, as the host culture and the minority culture, the Middle Eastern culture of the participant, as the heritage culture. This project examines the intragroup differences of acculturation on an individual scale, and as such, the discussion will refer to individual concepts of acculturation.
Acculturation is often operationalized as either a uni-dimensional or bi-dimensional measurement. A uni-dimensional model is one that interprets acculturation as a process where an individual changes from one cultural orientation to another, often moving from heritage to host cultural orientations (Spindler, 1955). On the other hand, a bi-dimensional model accounts for an individuals ability to identify with both host and heritage culture and does not conceptualize acculturation as a linear change from one culture to another (McFee, 1968; Berry 1997). The study utilizes a bi-dimensional model, which has been argued to provide more nuanced information about acculturation and its outcomes (Fox et al., 2017).
The conceptualization of acculturation has been inconsistent between studies in the social sciences and health and many studies do not clearly define their conceptualization.
One inconsistency in measurement pertains to temporality. While much research employs a current state status measure (Berry, 2003), some studies of acculturation measure amount of cultural change (Rudmin, 2009). Though acculturation is a process of cultural change over time and using a change over time model could be beneficial to health research (Fox et al., 2017), the study adopts a current state conceptualization as the stress measurements, both self-reported and biomarker, represent a short period of time circa the survey. I also utilize a current state model because the participants in the study represent 1st, 2nd and later generation individuals, and as such, all have different acculturation intercepts, or starting points
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(Castro et al., 2010; Lopez-Class et al., 2011). Different acculturation intercepts influence how much cultural change an individual experiences over his or her lifetime and greater change may impact health more because there is a larger cultural distance that needs to be traversed (Fox et al., 2017). Because of the varied nativity of the participants, the study focused on an individuals current acculturation status and how it is related to stress levels during the same time period.
One of the most common bi-dimensional frameworks used in modem acculturation research is Berrys four category model which splits an individual or group into either an integrated, separated, assimilated, or marginalized category (Berry, 1992). If an individual is considered integrated, then the person retains his or her heritage culture while gaining the culture of the majority. Separated individuals are those who identify strongly with just their heritage culture but do not interact with the host culture, whereas assimilated individuals are those who interact with host culture and do not maintain their heritage culture. Finally, marginalized individuals are those who do not adopt or maintain either host or heritage culture. This conceptualization of acculturation is bi-dimensional, that is, it accounts for an individuals ability to identify and navigate with both, one or the other, or neither of the cultures and that the orientation to one culture does not reflect the orientation to another. Because of the four categorys bi-dimensionality and popularity in acculturation research, this is the model that was chosen for this research project.
1.2 The Context Of Acculturation For Middle Eastern Americans
Not only can a researchers definition of acculturation affect interpretation and acculturation outcomes, but the social, political and cultural context within which acculturation occurs can have important impacts on the acculturative process. The cultural
3


adjustments that occur, that is the changes to behaviors, beliefs, or identity that groups or individuals undergo, are influenced by a number of socio-cultural factors (Fox et al., 2017b). While there are many different sociocultural factors to consider, three that might influence acculturation in the present study are demographic makeup of the area in which people live, discrimination, and difference between heritage and host culture (Fox et al., 2017b).
The type of immediate neighborhood that an individual is living in, whether predominately host (e.g. white American) or predominately the heritage culture, can influence the acculturation trajectories (Castro, et al. 2010; Schwartz, et al. 2006). For example, some studies show that in Hispanic neighborhoods that are composed almost entirely of people sharing a heritage culture, individuals often do not have to go through many of the aspects of acculturation like learning the host countrys customs or language (Schwartz, et al. 2010). The neighborhood composition of the Denver and Boulder metro areas where the study was conducted is predominately white and Hispanic and Latino (US census data, 2010). This composition could likely have an effect on the different acculturation trajectories represented.
Discrimination could either increase acculturation processes by encouraging an individual to become more like the host culture, or by causing an individual to not participate in host cultural norms because of the unwelcoming and hostile environment of the host country (Fox et al., 2017b). A study by Te Lindert, et al. 2008, conducted in the Netherlands, found that Iranian refugees retained their heritage cultural orientation when there were higher levels of perceived discrimination, and increased host cultural orientation when there was less perceived discrimination. Discrimination is also important to consider because many of the negative health effects, like stress and mental health issues, that researchers report from
4


acculturation could in fact result from discrimination (Rudmin, 2009). Many Middle Eastern Americans experience discrimination in the United States, with notable increases occurring after the event of September 11th (Rousseau et al., 2011; Abu-Ras and Abu-Bader, 2008), and more recently, leading up to 2016 Presidential election (FBI Statistics on Hate crimes, 2015; Levin, 2016). This increase in discrimination, when combined with the current political climate in the United States, could have a notable impact on MEAs acculturation trajectories and physical stress levels. As such, it was important to address discrimination in the survey on acculturation trajectories.
The difference between heritage and host culture may also greatly influence the acculturation trajectory of an individual, with greater cultural differences between the heritage and host culture causing more instances of stress and poorer health (Fox et al., 2017b). Young MEAs are positioned between two distinct, sometimes conflicting cultures, the Middle Eastern culture of their heritage and the Western American culture in which they live. One major source of conflict between American and Middle Eastern cultures is when young MEA adults and their parents have different cultural values, with parents favoring more traditional values and children wishing to participate in Western society (Haddad and Smith, 1996; Eisenlohr, 1996). This conflict reflects the notable differences between Middle Eastern and American cultures which may moderate the acculturation of MEA individuals. How young MEA adults respond to these discrepancies varies greatly between individuals (e.g. Ahmed, 2011; Gokariksel and McLarney, 2010; Bayoumi, 2008; Read and Bartkowski, 2000). First hand accounts of MEAs experiences show that there are a variety of ways to respond to their unique cultural situation, with some young adults embracing or rejecting either the Western culture where they grew up or the Middle Eastern culture of their parents.
5


Still others describe how they choose a middle road between the two (Bayoumi, 2008), reflecting a more integrated acculturation trajectory. While the study does not directly address these issues of cultural discrepancies, it is important to point out that these factors could have an effect on the acculturation trajectories of MEAs, especially considering the degree of difference between many MEAs cultures and the culture of the United States.
1.3 Acculturation and Health
Recently, acculturation has become a topic of great interest in public health studies that seek to understand how acculturation could affect the health of an individual or group. Though there is little consistency across studies of acculturation and health, most demonstrate some relationship between acculturation and the health of groups and individuals (Abraido-Lanza, et al. 2006). For example, assimilation has been found to be both a risk factor to various diseases like diabetes (Stern et al., 1992) and low birth weight (Cervantes et al., 1999), and a protective factor for health behaviors, like increased use of health services (Clark, 2002) in Latino populations in America (Lara et al., 2005). The same could be said for studies examining acculturation and health in Asian American populations (Suinn, 2010). For example, high acculturation has been found to be a protective factor in Korean American men, but a risk factor in Korean American women (Song et al., 2004). On the other hand, low acculturation has been associated with psychological adjustment issues in Chinese and Taiwanese students (Wang and Mallinckrodt, 2006). The effects of acculturation on health can be seen outside of the United States as well, a study examining cultural consonance (the degree to which individuals approximate the beliefs and behaviors of their surrounding cultures) found that low cultural consonance was associated with high psychological distress in Brazil (Dressier et al., 2017). The discrepancies could be caused by
6


a variety of issues from how acculturation is operationalized (Fox et al., 2017a), to not properly addressing cofactors and moderators of acculturation (Fox et al., 2017b). However, what these studies highlight is that acculturation does have an influence on the health of individuals, albeit in context-specific ways.
While work looking specifically at Arabic and Middle Eastern individuals has not been examined extensively, what has been done also shows that acculturation can have differential effects on health. One study reported that a lack of assimilation in Arabic individuals who immigrated to the US was an important risk factor for diabetes (Jaber et al., 2003). Another found that Arabic Americans who reported moderate ethnic identity to both Arabic and American cultures, that is those who were more integrated, had better self-reported physical health, whereas individuals who were more assimilated reported better mental health (Jadalla and Lee, 2012). One last example demonstrated that Arabic American individuals who were more separated reported better nutritional and stress management practices, whereas individuals who were more assimilated reported better physical activity and interpersonal relationships (Jadalla et al., 2015). These studies highlight how acculturation can affect health in Middle Eastern American communities in a variety of different ways and as such more work needs to be conducted to fully tease apart how acculturation impacts health in minority groups.
One proposed way that acculturation can affect the health of an individual is through psychosocial stress, specifically, what is termed acculturative stress (Berry and Annis, 1979; Berry et al., 1987). Acculturative stress is the stress that a person might experience when going through the process of acculturation and cultural change, with those who experience more cultural change between differing cultures experiencing more acculturative
7


stress (Fox et al., 2017b; Berry and Annis, 1979). Acculturative stress may be the cause of many of the negative health effects associated with acculturation. For example, in a study examining depression symptoms in Mexican-American pregnant women, acculturative stress, defined as the amount of cultural change an individual experiences, and a mixture of Mexican and American values, was associated with elevated depression symptoms (D'Anna-Hemandez et al., 2015). Similarly, a study found that in elderly Arabic individuals acculturative stress predicted depression (Howells Wrobel et al., 2009). While acculturative stress may have an effect on health outcomes, interestingly, research has generally shown that those who are integrated experience less stress than individuals who are assimilated or separated, and those, in turn, experience less stress than marginalized individuals (Berry, 2005). This relationship between acculturation strategies, acculturative stress, and health needs to be further explored to fully understand the processes involved in the development of adverse health outcomes.
1.4 Research Goals
Elucidating the relationship between acculturation and stress will provide researchers and policy makers alike better knowledge on how to combat health issues that minorities and migrants face in the United States. As discussed above, past work has shown that acculturation can have an effect on perceived stress and mental health in minority populations (Nguyen and Benet-Martinez 2013; Padilla, 2006). This study aims to add to our understanding of acculturations effects on the health of minority and migrant populations. Specifically, I studied acculturation, perceived stress, self-esteem, depression and discrimination of young Middle Eastern American (MEA) students living in the Denver and Boulder metro areas. Data were gathered on these factors through an online survey to
8


describe and determine if there are any relationships between acculturation, perceived stress, self-esteem, depression and discrimination.
Acculturation has a positive impact on health in other minority populations in America, though results vary greatly (Suinn 2010; Lara, et al. 2005). Possible explanations for this association are that individuals who are integrated in both their heritage culture and American culture can navigate different social situations and also have larger support groups to rely on (Padilla, 2006). As such, I predict that integrated individuals will have the lowest levels of self-reported stress, the highest levels of self-esteem, and the lowest levels of depression. I also predict that discrimination will have a mediating effect on acculturation category, with individuals who experience higher discrimination being the least likely to be integrated.
This project is novel in that it seeks to understand the relationship between acculturation and chronic stress among young MEA. These aims will provide valuable insight into how the acculturation trajectories of young adults affect their physiological stress levels, which in turn can greatly impact their health. Young MEA adults are in a unique position, trying to find the balance between two, often conflicting cultures. Considering the current migration patterns of MEA individuals, and their growing role in American society, this project could offer topical insight into how young MEAs deal with integrating into both of their cultures. Finally, this project may have broader impacts for research on cultural identity in other minority groups in helping to elucidate the factors involved in acculturation and stress. These insights into acculturation and stress could further inform public policy directed towards increasing awareness of acculturation processes, decreasing stress, and improving the lives and health of multicultural individuals in the United States.
9


CHAPTER TWO
METHODS
2.1 Recruitment
Participants were recruited from the downtown Auraria campus in Denver and the University of Colorado, Boulder campus. Student organizations and interest groups were contacted and helped to disseminate information about the study to their members. Participants were also recruited in person by the researchers who attended student group meetings and events to talk about the project. Finally, flyers with information on the online survey were posted around both campuses. Participants were encouraged to share information about the research project and survey to their friends and family to facilitate snowball recruitment. Everyone who participated in the survey was entered to win one of five $20 visa gift cards and individuals who participated in the follow up study were compensated $10.
2.2 Participant Demographics
Participants were between the ages of 18-35 and were living in the Denver and Boulder areas. They were either first, second or third generation MEA adults. Complete data were available from 43 participants.
2.3 Survey Measures
The survey was created through CU Denvers Redcap service. See appendix A for full survey.
The survey included questions on basic demographic, perceived stress, self-esteem, depression, discrimination and acculturation. The survey instruments used were established and validated by previous studies and included the Perceived Stress Scale (PSS) (Cohen et
10


al., 1983), the Rosenberg Self Esteem Scale (Rosenberg, 1965), the Everyday Discrimination Scale (Williams et al., 1997), the Center for Epidemiological Studies Depression Scale Revised (CESD-R) (Radloff, 1997), and the General Ethnicity Questionnaire (GEQ) (Tsai et al., 2000). The GEQ was the instrument chosen to measure acculturation and is a two part, 38 items per part survey that assesses both heritage and host cultural orientations. The questionnaire asks the same questions in both parts about behaviors, practices and language use for each culture (e.g. I was raised in way that was American; I was raised in way that was Lebanese). These items are scored on a 1-5 point Likert scale with 1 meaning strongly disagree to 5 meaning strongly agree for items pertaining to behavior and practice, and 1 meaning very much to 5 meaning not at all for language items. The GEQ was chosen as the instrument to measure acculturation because it is a bi-dimensional scale, that is, it measures an individuals cultural orientation for both the heritage and host cultures, allowing an individual to identify with both, one or the other, or neither. Another strength of the GEQ is its ability to be customized to the specific cultural group being studied. For this particular study, participants identified the cultural group they best identified with (e.g Lebanese, Saudi Arabian, Turkish, etc.) and this culture was then used in the heritage culture part of the GEQ.
The survey also included questions that addressed possible confounding variables. Data were also collected on age, socioeconomic status, education level, 1st, 2nd, or 3rd generation status (here defined as first generation are individuals who immigrated to the United States), and religiosity. Like the survey instruments discussed above, the instruments used for confounding variables have also been validated by previous studies and include and the Duke University Religion Index (DUREL) (Koenig and Bussing, 2010). See Appendix A for a copy of the full survey.
11


Perceived stress was scored by reverse coding the values of positively stated questions (i.e 0=4, 1=3, 2=2, 3=1, 4=0) and then summing the questions together (Cohen, 1983). Self esteem was scored by assigning 1 point for strongly disagree up to 4 for strongly agree and reverse scoring negatively phrased questions and summing the scores for all items (Rosenberg, 1965). Discrimination was scored by assigning the value of 0 for responses of never up to 3 for responses of often and the items were summed for an overall discrimination score (Williams et al., 1997). The CESD-R was scored by assigning 0 points from not at all up to 3 for nearly every day and then summing all items together, with the higher scores representing more depressive feelings (Radioff, 1997). The cultural identity groups were scored by coding all the items the same and then calculating a mean of all the items for an overall cultural orientation score (Tsai et al., 2000). Participants were then classified into one of Berrys (1980) four acculturation categories: integrated, assimilated, separated, or marginal. Individuals who scored above the midpoint (i.e mean is higher than
2.5 on a 5 point scale) for both the heritage and American scales were coded as integrated; those who scored above the midpoint on the American scale but below the midpoint on the heritage scale were coded as assimilated; as follows: those who scored below the midpoint on the American scale but above the midpoint on the heritage scale were coded as separated; and those who coded below the midpoint on both the American and heritage scales were coded as marginal (Ying et al., 2000).
2.4 Statistical Analysis
Descriptive statistics were used to determine the mean and standard deviation for perceived stress, self-esteem, depression, discrimination, and blood pressure. After calculating cultural orientation scores for heritage and host cultures, participants were sorted
12


into integrated, assimilated, separated, and marginal categories and the prevalence of each was assessed. Using these categories a one-way ANOVA was performed to see if there were differences in average perceived stress levels between the four groups. Differences in average self-esteem, depression, and discrimination scores between the integrated, assimilated, separated and marginal groups were addressed by performing a separate t-test for each group pairing. Partial correlations were run to determine if there was a relationship between heritage and host cultural identity scores and stress, self-esteem, depression and discrimination. P < .05 was used to indicate statistical significance and all statistics were run in IBM SPSS, v. 24.
13


CHAPTER THREE
RESULTS
3.1 Summary Statistics Of Population Characteristics
The summary statistics for the study can be seen in Table 1. The study population included only integrated (n=35) and assimilated (n=10) individuals. The average age was of the study sample was 23.1 years (std=4.4 years). Forty-five percent of the study population was female, and there was one person who self-identified as other. Most participants were dependents (62%), and most were first (38%) and second (33%) generation young adults. Summary statistics comparing the two acculturation categories are shown in table 2.
Table 1: Summary statistics for population characteristics (standard deviations in parenthesis)
Survey descriptive statistics
Percentage/ mean N
Female 45% 21
Male 53% 23
Other 2% 1
Dependent 62% 28
Independent 36% 16
Other financial 2% 1
1st generation 38% 17
2nd generation 33% 15
3rd generation 29% 13
Integrated 78% 35
Assimilated 22% 10
Age (mean) 23.1 (4.4) 45
Heritage COS (mean) 3.6 (.6) 45
US COS (mean) 3.9 (.3) 45
Perceived stress score (mean) 18.6 (6.1) 45
Self-esteem score (mean) 20.7 (6.3) 45
Depression (mean) 17.3 (11.1) 45
Discrimination (mean) 1.7(1.1) 45
Religiosity score (mean) 9.6 (3.7) 45
14


Table 2: Summary statistics for population characteristics comparing integrated and
assimilated categories(standard deviations in parentheses).
Integrated Assimilated
n=35 n=10
Age (average) 22.9 (4.3) 25.25(5.3)
Female (n) 15 6
Male (n) 19 4
Other (sex) 1 0
Dependent (n) 21 7
Independent (n) 13 3
Other (financial) 1 0
1st generation (n) 16 1
2nd generation (n) 10 5
3rd generation (n) 9 4
Heritage COS (mean) 3.9(.4) 2.1(3)
US COS (mean) 3.9(.3) 4.0(.l)
Perceived stress score (mean) 17.0(5.4) 23.1(6)
Self esteem score (mean) 19.8(6.5) 24.4(4)
Depression score (mean) 14.3(9.7) 29.0(9.8)
Discrimination score ( mean) 1.6(1.1) 1.8(.76)
Religiosity score (mean) 10.1(3.8) 7.3(2.8)
3.2 ANOVA Comparing Perceived Stress, Self-Esteem, Depression, And Discrimination For Integrated And Assimilated Groups
There was a significant difference between the mean perceived stress score (F=7.1; p=01), the Rosenbergs self-esteem score (F=4.3; p=.04) and the CESD-R depression score (F=14.3; p< 01) between groups, with integrated individuals reporting lower levels of stress, self-esteem and depression when compared to assimilated individuals. There was no significant difference (p=. 8) between mean discrimination scores for integrated and assimilated individuals.
Table 3: ANOVA results for comparing means of PSS, self-esteem, CESD-R, and EDS between integrated and assimilated individuals
P-value F statistic
Perceived stress <01 7.1
Self-esteem <.04 4.3
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Table 3 contd
Depression <01 14.3
3.3 Correlations Between Cultural Orientation Scores And Stress, Self-Esteem, Depression, And Discrimination.
There was a negative significant, moderate correlation between a persons heritage cultural orientation score and perceived stress (r=-.32, p=.05) and depression (r=-.331, p=-.05) (table 2). The US cultural orientation score only had one near significant, positive correlation with perceived stress (r=.308; p=.06). Discrimination was correlated with neither heritage nor US cultural orientation scores and only had a moderate, positive correlation with perceived stress (r=.342; p=.047) and depression (r=.329; p=.05).
Table 4: Correlations table for cultural identity scores and stress, self-esteem, depression, and
discrimination, controlling for religion, sex, financial status, generational status, and age.
Heritage orientation Host orientation Perceived Stress Self-esteem Depression
Host orientation -.212 -
Perceived stress -.320* .308 -
Self-esteem -.227 .038 .161 -
Depression -.331* .177 .766** .243 -
Discrimination .158 .14 .342* .035 .329*
*p<05, **p< 01
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CHAPTER FOUR
DISCUSSION
Public health research has become increasingly interested in acculturation and health, especially as the United States continues to become more diverse and multicultural (Abraido-Lanza, et al. 2006). The study aimed to further pick apart the relationship between acculturation and mental health in Middle Eastern Americans by examining survey data on acculturation, stress, self-esteem, and depression. The results show that there is clearly a relationship between acculturation trajectories of Middle Eastern Americans and their psychological outcomes. We found that integrated individuals had lower levels of stress, depression and self-esteem, whereas assimilated individuals all had higher levels of stress, depression and self-esteem. These results are discussed in depth below, as well as, possible future directions acculturation research can take.
The results of the one-way ANOVA partially supported my hypotheses. Integrated individuals had significantly lower stress and depression levels than assimilated individuals. These results support past research and demonstrate that being integrated can have a positive impact on an individuals health (e.g. Padilla, 2006). Identifying with both an individuals host and heritage culture has a protective effect on stress and depression. This protective nature of integration is likely due to the increase in social support in both the public (friends) and private (family) spheres. It may be also be related to a decrease in stressful cultural interactions between an individual and the two cultural environments they have to navigate. However, assimilated individuals had, on average, higher levels of self-esteem than their integrated counterparts. This relationship has been reported in some previous research on acculturation and self-esteem (Meyer et al., 2005), though other studies support the initial
17


hypothesis that integrated individuals would have the best self-reported psychological outcomes (Vasquez et al., 2011).
The results of the partial correlations further highlight the unexpected relationship between heritage culture and self-esteem. The heritage cultural orientation score was negatively associated with all three psychological measures (though weak and nonsignificant for self-esteem, p=. 18), meaning that as heritage orientation increases, stress, depression and self-esteem all decrease. The reported relationship was expected for stress and depression and supports the ANOVA results. The lack of significant findings and the negative correlation for self-esteem was surprising, though is reflected in the ANOVA results discussed above. Assimilated individuals (those that report low heritage cultural orientation) have higher levels of self-esteem on average compared to integrated individuals (those with higher heritage scores). A number of factors could be influencing this relationship, such as host and heritage cultural values. American culture tends to emphasize the individual and individual rights (Hong et al., 2001). Many Middle Eastern cultures, on the other hand, emphasize family relationships and duties (Haddad and Smith, 1996; Kulwicki, 1996). These differences in cultural values may influence a persons self-esteem and depression depending on which cultural values are adopted. For example, an assimilated individual may adopt the American value of individualism, which would positively affect their self-esteem, while deemphasizing familial support, which may contribute to depression. Other studies reported similar results between acculturation and self-esteem, particularly in Hispanic populations (e.g. Meyer et al. 2005; Flaskerud and Uman 1996), though these studies do not discuss selfesteem as a cultural value. Exploring this idea of self-esteem as a cultural value would be useful for future research on acculturation.
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Depression and stress followed the expected pattern and were positively correlated to one another (Hammen, 2005). However, self-esteem was positively correlated to both perceived stress and depression (though again non-significant, p=.l and p=. 15, respectively), meaning the higher an individuals self-esteem score, the higher that persons stress and depression scores are as well. These results are contrary to past findings on the relationship between self-esteem, depression, and stress, which demonstrate that higher self-esteem protects against depression and stress (Moksnes et al., 2016; Orth and Robins, 2013). Selfesteems positive relationships with these two outcomes may reflect how influential acculturation can be on mental health outcomes. These results further emphasize the importance of continuing acculturation research to fully pick apart these complex relationships.
Partial correlations were also run to see how the continuous cultural orientation scores were related, if at all. There was a weak, though non-significant (p=.062), negative correlation between US cultural orientation score and the heritage cultural orientation score. This may be related to the study population, which includes first, second, and third generation young adults. The integrated group is composed of 44% first generation adults whereas the assimilated group was 44% third generation or later. This spread of first, second, and third generation students could have an effect on how the cultural orientation scores interact as these individuals all have different acculturation intercepts, or cultural starting points (Castro et al., 2010; Lopez-Class et al., 2011). Third generation individuals may have higher US orientation scores coupled with lower heritage cultural orientation scores because their starting point of acculturation is more engrained in US culture than their heritage culture.
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While generation status may have a slight effect on acculturation trajectories, it is still not a good proxy to use in lieu of direct acculturative measures. In order to test this, I ran one-way ANOVA to see if a different generation status affected stress, depression, and selfesteem. I found that there was no significant difference between generation status and stress (F=.93, p=.4) and depression (F=1.03, p=.36), though there was a signifigant effect on selfesteem (F=3.8, p=.03), whereas acculturation status had a significant effect on all three measures. This suggests that generation status is a poor substitution for validated acculturation measures. Future research on acculturation should strive to include not only generational status, but also direct acculturative measures like values, beliefs, behaviors, and actions (Fox et al., 2017b).
The US cultural orientation score was not significantly correlated to any of the psychological measures, but there was a moderate, positive, non-significant (p=.08) correlation with perceived stress. The increase in perceived stress that highly acculturated individuals experience could be related to a number of things. One possible factor, as described above, could be an individuals acculturation intercept. If an individual has a long cultural distance to traverse, like first generation individuals, then the amount of acculturative stress they experience may be higher, which could be reflected in their perceived stress scores (Fox et al., 2017b). Another possible factor is the cultural context of the host culture. For example, Americans report some of the highest everyday stress levels (i.e. work, day to day life stressors) in the world (American Psychological Association) and individuals who have higher perceived stress scores may be reflecting that aspect of American culture. Future research on acculturation should take an individuals cultural starting point, perhaps indexed by a retrospective survey or data on place of birth and number of locations lived, into
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account. It would also be useful to collect qualitative data on what the heritage and host cultures opinions or views are on the psychological measures being tested. For example, what are the perceived cultural differences related to the value of self-esteem between the host and heritage culture?
The vast majority of participants were integrated individuals (79%). The remaining 21% of the sample were assimilated, and there were no separated or marginal individuals. This distribution was likely influenced by the location of the study population, which was recruited from the CU Denver and Boulder campuses. As discussed above, the composition of an individuals neighborhood likely has an effect on acculturation trajectories (Castro, et al. 2010; Schwartz, et al. 2006). The neighborhoods of Denver and Boulder are predominantly white and Hispanic (US Census Data, 2010). This composition likely increased the number of interactions that MEAs had with the host culture and, in turn, influenced the populations acculturation trajectories. Though the study does not directly address this issue, it is important to note that it is probable the neighborhood composition of Denver and Boulder contributed to the studys lack of separated or marginalized individuals.
One result that was unexpected was the lack of effect that discrimination had on acculturation and cultural identity scores. I had hypothesized that discrimination would influence the acculturation trajectories of participants, yet in the results I do not see this occurring. This may be due to the acculturation composition of the participants, which represent only integrated and assimilated individuals. These individuals may not experience discrimination in the same way a separated or marginal person might. High levels of discrimination have been shown to discourage acculturation in some populations (Fox et al., 2017b; Te Lindert, et al. 2008), and the same may be true for Middle Eastern Americans who
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are separated or marginal. The average discrimination score of the participants was 1.7, (on a 0-5 scale), which represents a relatively low discrimination score (Williams et al., 1997). The very low discrimination score may be attributed to the political and social make up of the Denver and Boulder areas, which are generally very liberal, and future work should address this unexpected result. Regardless, low discrimination score could be contributing to the acculturation trajectories seen in the present study. Discrimination could still be having an effect on acculturation, however the study may not have enough variation in discrimination experience to see these effects.
One limitation of the study is the small sample size, which most likely contributed to only two acculturation categories being represented. Despite this limitation, I was able to partially support the hypothesis that integrated individuals have lower levels of stress and depression and I found significant relationships between heritage cultural orientation and the dependent variables. These data highlight many new possibilities for future research on acculturation. One area that the research highlights is the need for more work examining the relationship between acculturation and self-esteem. As discussed above, the results that were found were unexpected and future work should explore factors such as acculturation intercepts and overall cultural values should be explored in greater detail. Yet another interesting finding is how strong of a mitigating effect acculturation might be having on the relationship between self-esteem, stress and depression.
An important avenue for future research on acculturation and health is the collection of biomarker data collection. Biomarker data on stress can give a physical measure of stress along with the perceived measures from survey. For example, blood pressure is an established measure for higher chronic stress levels (Sweet, 2001; Gravlee and Dressier
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2005; Juster et al., 2010). Higher levels of chronic stress are associated with an increased risk of cardiovascular disease, likely through the activation of the sympathetic-adrenal-medullary (SAM) axis and the hypothalamic-pituitary-adrenal (HPA) axis which elicit a fight or flight response to stress (Sapolsky et al., 2000). This fight or flight reaction increases heart rate and vasoconstriction, which can lead to hypertension (Ayada et al.,
2015).
Cortisol is another useful biomarker of stress. It is a glucocorticoid produced in the adrenal cortex that increases when an individual experiences greater stress (Pollard and Ice, 2006). Hair cortisol is particularly good for measuring overall elevated levels of cortisol overtime (typically representing chronic stress over one to two months), and is not sensitive to diurnal variation making it a more reliable index of HPA-axis function when only a single measurement can be taken (Russell et al., 2010; Sauve et al., 2007). Hair cortisol, like blood pressure, is a relatively easy, non-invasive measurement to collect from participants and would greatly add to the understanding of stress and acculturation.
The United States is becoming an increasingly diverse and multicultural environment. The process of acculturation will therefore continue to be of interest to public health researchers and policy makers. The study demonstrates how influential acculturation can be on an individuals stress, self-esteem and depression while drawing attention to many vital future research paths. Integrated individuals demonstrated that there are advantages of being oriented to both host and heritage culture for stress and depression, but not for self-esteem. These results emphasize how important it is to conduct more research on acculturation and psychological outcomes, particularly self-esteem. The study also provides evidence against the use of proxies for acculturation research, as the proxy, generational status, did not
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produce significant results like the direct acculturation measure did. Future work on acculturation and health would benefit from direct acculturative measures as well as, direct biological measures. These data can help to improve the public health of minority and immigrant groups throughout the United States by demonstrating both the positive and negative effects of acculturation on mental and physical health. Policy makers and public health officials could use the present data and future research avenues discussed in this article to inform the public and improve the lives of multicultural individuals.
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Confidential
APPENDIX A
Page 1 of 19
Survey consent
Read the following attached consent form. [Attachment: "consent form survey final.docx"] Statement of consent:
Do you wish there to be documentation linking you to the research project?
Please provide your email address.
Thank you for your time. Please close this window now.
O I am 18 or older and consent to participating in this study as outlined above.
O I am under 18 OR do not consent to participating in this study as outlined above.
O Yes O No
Thank you for participating, please hit the "submit" button now.
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Page 2 of 19
Please complete the survey below.
Thank you!
Demographic Information
Age
Gender
What country were you born in?
If other, specify
What country was your father born in?
If other, specify your Father's country of origin What country was your mother born in?
If other, specify your mother's country of origin What is your highest level of education?
O Female O Male O Other O N/A
O United States O Other
O United States O Other O N/A
O United States O Other O N/A
O High school graduate O GED or equivalent O Associate degree O Bachelor's degree O Master's degree
O Professional school degree (e.g MD, DDS) O Doctoral degree O Other
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Page 3 of 19
13) Financially, are you dependent or independent? O dependent O independent O other
14) What is your total individual annual income? O Less than $25,000 O $25,000 through $34,999 O $35,000 through $39,999 O $50,000 through $74,999 O $75,000 through $99,999 O Mote than $100,000
15) What is your total annual household income (record parent or guardian's if dependent)? O Less than $25,000 O $25,000 through $34,999 O $35,000 through $39,999 O $50,000 through $74,999 O $75,000 through $99,999 O More than $100,000
16) What is your father's highest level of education? O High school diploma or equivalent O Associate degree O Bachelor's degree O Master's degree O Professional school degree (e.g MD, DDS) O Doctoral degree O Other O N/A
17) What is your mother's highest level of education? O High school diploma or equivalent (GED) O Associate degree O Bachelor's degree O Master's degree O Professional school degree (e.g MD, DDS) O Doctoral degree O Other O N/A
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Page 4 of 19
What nationality/ethnicity do you best identify with (e.g. Arabic, Persian, Turkish, Egyptian etc.)?
Strongly disagree Disagree Neutral Agree Strongly Agree N/A
1 was raised in way that was [ethnicity]. o o o o o o
When 1 was growing up, 1 was exposed to [ethnicity] culture. o o o o o o
Now, 1 am exposed to [ethnicity] culture. o o o o o o
Compared to how much 1 negatively criticize other cultures, 1 criticize [ethnicity] culture less. o o o o o o
1 am embarrassed/ashamed of [ethnicity] culture. o o o o o o
1 am proud of [ethnicity] culture. o o o o o o
[ethnicity] culture has had a positive impact on my life. o o o o o o
1 believe that my children should read, write, and speak [ethnicity]. o o o o o o
1 have a strong belief that my children should have [ethnicity] names only. o o o o o o
1 go to places where people are [ethnicity]. o o o o o o
1 am familiar with [ethnicity] cultural practices and customs. o o o o o o
1 relate to my partner or spouse in a way that is [ethnicity]. o o o o o o
1 admire people who are [ethnicity]. o o o o o o
1 would prefer to live in an [ethnicity] community. o o o o o o
1 listen to [ethnicity] music. o o o o o o
1 perform [ethnicity] dance. o o o o o o
1 engage in [ethnicity] forms of recreation. o o o o o o
1 celebrate [ethnicity] holidays. o o o o o o
At home, 1 eat [ethnicity] food. o o o o o o
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Page 5 of 19
At restaurants, 1 eat [ethnicity] food. O O O O o
When 1 was a child, my friends were [ethnicity]. O O O o o
Now, my friends are [ethnicity]. O O O o o
1 wish to be accepted by [ethnicity]. O O O o o
The people 1 date are [ethnicity]. O O O o o
Overall, 1 am [ethnicity]. O O O o o
In your cultural or ethnic community do you speak... O Arabic
O Farsi O Other
If other, please specify
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O O O O


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Page 7 of 19
Very much Much Somewhat A little Not at all
How much do you speak [ethnicity_language_other] at home? O o o o o
How much do you speak [ethnicity_language_other] at school? o o o o o
How much do you speak [ethnicity_language_other] at work? o o o o o
How much do you speak [ethnicity_language_other] at prayer? o o o o o
How much do you speak [ethnicity_language_other] with friends? o o o o o
How much do you view, read, or listen to [ethnicity language other] on TV? o o o o o
How much do you view, read, or listen to [ethnicity language other] in film? o o o o o
How much do you view, read, or listen to [ethnicity_language_other] on the radio? o o o o o
How much do you view, read, or listen to [ethnicity_language_other] in literature? o o o o o
How fluently do you speak [ethnicity_language_other]? o o o o o
How fluently do you read [ethnicity_language_other]? o o o o o
How fluently do you write [ethnicity_language_other]? o o o o o
How fluently do you understand o o o o o
[ethnicity_language_other]?
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Page 8 of 19
On a scale of one to five, indicate how much you agree with the following statements.
Strongly disagree Disagree Neutral Agree Strongly Agree N/A
72) 1 was raised in way that was American. o o o o o o
73) When 1 was growing up, 1 was exposed to American culture. o o o o o o
74) Now, 1 am exposed to American culture. o o o o o o
75) Compared to how much 1 negatively criticize other cultures, 1 criticize American culture less. o o o o o o
76) 1 am embarrassed/ashamed of American culture. o o o o o o
77) 1 am proud of American culture. o o o o o o
78) American culture has had a positive impact on my life. o o o o o o
79) 1 believe that my children should read, write, and speak English. o o o o o o
80) 1 have a strong belief that my children should have American names only. o o o o o o
81) 1 go to places where people are American. o o o o o o
82) 1 am familiar with American cultural practices and customs. o o o o o o
83) 1 relate to my partner or spouse in a way that is American. o o o o o o
84) 1 admire people who are American. o o o o o o
85) 1 would prefer to live in an American community. o o o o o o
86) 1 listen to American music. o o o o o o
87) 1 perform American dance. o o o o o o
88) 1 engage in American forms of recreation. o o o o o o
89) 1 celebrate American holidays. o o o o o o
90)
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Page 9 of 19
At home, 1 eat American food. O o o o o o
91) At restaurants, 1 eat American food. O o o o o o
92) When 1 was a child, my friends were American. O o o o o o
93) Now, my friends are American. O o o o o o
94) 1 wish to be accepted by Americans. O o o o o o
95) The people 1 date are American. O o o o o o
96) Overall, 1 am American. O o o o o o
Please use the following scale to answer the following questions.
Very much Much Somewhat A little Not at all
97) How much do you speak English at home? o o o o o
98) How much do you speak English at school? o o o o o
99) How much do you speak English at work? o o o o o
100) How much do you speak English at prayer? o o o o o
101) How much do you speak English with friends? o o o o o
102) How much do you view, read, or listen to English on TV? o o o o o
103) How much do you view, read, or listen to English in film? o o o o o
104) How much do you view, read, or listen to English on the radio? o o o o o
105) How much do you view, read, or listen to English in literature? o o o o o
106) How fluently do you speak English? o o o o o
107) How fluently do you read o o o o o
108) ^S^J'fltifently do you write o o o o o
109) ^S^J'fltifently do you understand o o o o o
English?
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Page 10 of 19
Instructions
Below is a list of statements dealing with your general feelings about yourself. Please indicate how strongly you agree or disagree with each statement.
110) 1. On the whole, 1 am satisfied with myself. O Strongly Agree O Agree O Disagree O Strongly Disagree
Ill) 2. At times 1 think 1 am no good at all. O Strongly Agree O Agree O Disagree O Strongly Disagree
112) 3. 1 feel that 1 have a number of good qualities. O Strongly Agree O Agree O Disagree O Strongly Disagree
113) 4. 1 am able to do things as well as most other people. O Strongly Agree O Agree O Disagree O Strongly Disagree
114) 5. 1 feel 1 do not have much to be proud of. O Strongly Agree O Agree O Disagree O Strongly Disagree
115) 6. 1 certainly feel useless at times. O Strongly Agree O Agree O Disagree O Strongly Disagree
116) 7. I feel that I'm a person of worth, at least on an O Strongly Agree
equal plane with others. O Agree
117) 8. 1 wish 1 could have more respect for myself. O Disagree O Strongly Disagree O Strongly Agree O Agree O Disagree O Strongly Disagree
118) 9. All in all, 1 am inclined to feel that 1 am a failure. O Strongly Agree O Agree O Disagree O Strongly Disagree
119) 10. 1 take a positive attitude toward myself. O Strongly Agree O Agree O Disagree O Strongly Disagree
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0 = Never 11 = Almost Never 12 = Sometimes 13 = Fairly Often / 4 = Very Often
120) 1. In the last month, how often have you been upset because of something that happened unexpectedly? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
121) 2. In the last month, how often have you felt that you were unable to control the important things in your life? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
122) 3. In the last month, how often have you felt nervous and "stressed"? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
123) 4. In the last month, how often have you felt confident about your ability to handle your personal problems? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
124) 5. In the last month, how often have you felt that things were going your way? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
125) 6. In the last month, how often have you found that you could not cope with all the things that you had to do? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
126) 7. In the last month, how often have you been able to control irritations in your life? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
127) 8. In the last month, how often have you felt that you were on top of things? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
128) 9. In the last month, how often have you been angered because of things that were outside of your control? O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
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129) 10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
O 0 = Never O 1 = Almost Never 0 2 = Sometimes 0 3 = Fairly Often 0 4 = Very Often
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Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way DURING THE PAST WEEK.
130) 1. I was bothered by things that don't usually bother me.
131) 2. I did not feel like eating; my appetite was poor.
132) 3. I felt that I could not shake off the blues even with the help of my family or friends.
133) 4. I felt that I was just as good as other people.
134) 5. I had trouble keeping my mind on what I was doing.
135) 6. I felt depressed.
136) 7. I felt everything I did was an effort.
137) 8. I felt hopeful about the future.
138) 9. I thought my life had been a failure.
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
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139) 10. I felt fearful.
140) 11. My sleep was restless.
141) 12. I was happy.
142) 13. I talked less than usual.
143) 14. I felt lonely.
144) 15. People were unfriendly.
145) 16. I enjoyed life.
146) 17. I had crying spells.
147) 18. I felt sad.
148) 19. I felt that people disliked me.
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
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149) 20. I could not get "going". O Rarely or none of the time (less than 1 day)
O Some or a little of the time (1-2 days)
O Occasionally or a moderate amount of the time (3-4 days)
O Most or all of the time (5-7 days)
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150) How often do you attend group prayer or other religious meetings?
151) How often do you spend time in private religious activities, such as prayer, meditation or the study of religious texts?
O Never
O Once a year or less O A few times a year O A few times a month O Once a week O Mote than once/week
O Rarely or never O A few times a month O Once a week O Two or more times/week O Daily
O More than once a day
The following section contains 3 statements about religious belief or experience. Please mark the
extent to which each statement is true or not true for you.
Definitely not true Tends not to be true Unsure Tends to be true Definitely true of me
152) In my life, 1 experience the presence of the Divine o o o o o
153) My religious beliefs are what really lie behind my whole approach to life o o o o o
154) 1 try hard to carry my religion over into all other dealings in life o o o o o
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In your day-to-day life, how often do any of the following things happen to you?
A most At east once A few times a A few times a Less than Never
everyday a week
You are treated with less courtesy than other people are. o o
You are treated with less respect than other people are. o o
You receive poorer service than other people at restaurants or stores. o o
People act as if they think you are not smart. o o
People act as if they are afraid of you. o o
People act as if they think you are dishonest. o o
People act as if they're better than you are. o o
You are called names or o o
Yl^ciP^threatened or harassed. o o
What do you think is the main reason for these experiences? (You may check more than one).
month year once a year
o o o o
o o o o
o o o o
o o o o
o o o o
o o o o
o o o o
o o o o
o o o o
Your Ancestry or National Origins
Your Gender
Your Race
Your Age
Your Religion
Your Height
Your Weight
Some other Aspect of Your Physical Appearance
Your Sexual Orientation
Your Education or Income Level
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Since the 2016 US presidential election have you...
not at all a little bit moderately quite a bit extrememly
felt upset when something or someone reminds you of what happened? o o o o o
had repeated memories, thoughts, or dreams about what happened? o o o o o
had difficultly concentrating? o o o o o
had trouble falling or staying asleep? o o o o o
felt irritable, on edge, or had angry outbursts? o o o o o
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Read the following attached consent form for the OPTIONAL follow up study. [Attachment: "biomarker consent form 16-0669.docx"]
Statement of consent:
Optional: I consent to allow the researcher to take photographs of the hair and blood pressure collection to be used in future presentations.
What is your height (in inches)?
What is your weight (in pounds)?
How often do you wash your hair?
Have you dyed your hair in the last three months? Did you or will you be observing Ramadan in 2016?
O I am 18 or older, have read and understand the information provided, and I consent to taking part in this study.
O I am under 18 OR do not consent to taking part in the follow up portion of this study
O Yes
O No
O everyday O 3-4 times a week O 1-2 times a week O every other week
O yes O no
O yes O no
In order to schedule a follow up meeting time, please enter your email.
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DISS_title THE EFFECTS OF ACCULTURATION ON PSYCHOLOGICAL STRESS MEASURES IN YOUNG MIDDLE EASTERN AMERICAN ADULTS
DISS_dates
DISS_comp_date 2017
DISS_accept_date 01/01/2017
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DISS_para Acculturation is the cultural adjustment that a group or individual experiences when previously separate cultures interact with one another. Understanding this process is important for immigrant and minority groups in the United States, who commonly navigate two or more distinct cultures. This research sought to understand how an individual’s acculturation trajectory, that is whether they are assimilated, integrated, separated, or marginalized, affected psychological measures. The acculturation trajectories, perceived stress, self-esteem, and discrimination in young adult first, second, and third generation Middle Eastern Americans who were living in the Denver metro area were studied. Online survey data on acculturation, perceived stress and self-esteem were collected from 43 adults (ages 18-35) who identified as Middle Eastern American. The results of the analysis suggest that acculturation trajectories vary across individuals, and these differences can have important impacts on perceived stress and other psychological outcomes. This research furthers our understanding of the impacts that acculturation can have on the mental health of migrant and minority individuals. These results will inform future studies and influence policies, like increasing community awareness of acculturation through educational programs that could improve the lives and health of immigrants and minorities in the United States.
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! THE EFFECTS OF ACCULTURATION ON PSYCHOLOGICAL STRESS MEASURES IN YOUNG MIDDLE EASTERN AMERICAN ADULTS b y MEREDITH WILSON B.A., Dickinson College 2013 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master s of Arts Anthropology Program 2017

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! ii This thesis for the Master of Arts degree by Meredith Wilson h as been approved for the Anthropology Program by David Tracer, Chair Zaneta M. Thayer advisor Sarah Horton Date: May 13 th 2017

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! iv Wilson, Meredith (MA, Anthropology Program) The Effects Of Acculturation On Psychological Stress Measures In Young Middle Eastern American Adults Thesis directed by Professor David Tracer ABSTRACT Acculturation is the cultural adjustment that a group or individual expe riences when previously separate cultures interact with one another. Understanding this process is important for immigrant and minority groups in the United States, who commonly navigate two or more distinct cultures. This research sought to understand how an individual's acculturation trajectory, that is whether they are assimilated, integrated, separated, or marginalized, affected psychological measures T he acculturation trajectories, perceived stress, self esteem, and discrimination in young adult first second, and third generation Middle Eastern Americans who were living in the Denver metro area were studied Online survey data on acculturation, perceived stress and self esteem were collected from 43 adults (ages 18 35) who identified as Middle Eastern American. The results of the analysis suggest that acculturation trajectories vary across individuals, and these differences can have important impacts on perceived stress and other psychological outcomes. This research furthers our understanding of the i mpacts that acculturation can have on the mental health of migrant and minority individuals. These results will inform future studies and influence policies, like increasing community awareness of acculturation through educational programs that could impro ve the lives and health of immigrants and minorities in the United States. The form and content of this abstract are approved. I recommend its publication. Approved: David Tracer

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! iii ACKNOWLEDGEMENTS This thesis has been approved by the COMIRB, protocol #16 099.

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! v TABLE OF CONTENTS CHAPTER I. INTRODUCTION.... .... 1 What Is A cculturation? .. .... .. .. .. .....1 The Context Of Acculturation For Young Middle Eastern Americans ...3 Acculturation and Health....... ...6 Research Goals .. .........8 II. METHODS ..10 Recruitment ..........10 Participant Demographics..... ......10 Survey Measures ..........10 Stat istical Analysis ... ....12 III. RESULTS .... ....14 Summary Statistics Of Population Characteristics. .14 T Tests Comparing Perceived Stress, Self Esteem, Depression And Discriminations For Integrate d And Assimilated Groups..... ..15 Correlations Between Cultural Orientation Scores And Stress, Self Esteem, Depression, And Discrimination 16 IV. DISCUSSION .... ..17 REFERENCES.. .... ..25 APPENDIX .31

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! vi A. Online S urvey.... ....31

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! vii LIST OF TABLES TABLE 1. Summary statistics for population characteristics (standard deviations in parentheses) .14 2 Summary statistics for popu lation characteristics comparing integrated and assimilated categories (standard deviations in parentheses) ....1 5 3 ANOVA results for comparing means of PSS, self esteem, CESD R, and EDS between integrated and assimilated individuals 1 5 4 Correlations table for cultural identity scores and stress, self esteem, depression and discrimination, controlling for religion, sex, financial status, generational status, and age 16

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! 1 CHAPTER ONE INTRODUCTION An individual's health is influenced by many different factors including their social and cultural environment One such factor, which is of great interest in the public health research of minority groups in America is the process of acculturation (AbraÂ’do Lanza, et al. 2006) Research on acculturation is becoming more pertin ent with the increase in globalization and cultural interactions in our society. Recen tly, acculturation has become of interest to public health research ers as many recognize the possible effects acculturation can have on both individual and population health One pathway through which acculturation may affect health is throug h increased levels of psychosocial stress ( Berry, et al. 1987 ). Increased levels of psychosocial stress have been associated with increased prevalence of hypertension, car diovascul ar disease and obesity (e.g. McInnis CM et al. 2014; Juster et al., 2010 ). As such, it is important for researchers to continue to study how acculturation and stress are related in order to better address health disparities 1.1 What Is Acculturation ? The study of acculturation and its effects on individuals and groups is becoming increasingly important in our globalized society. Historically, the process of acculturation has been studied in anthropology (e.g. Boas, 1888; Redfield, et al. 1936) but more r ecently has become of interest to public health studies as acculturation may have significant effects on the health of minority populations ( AbraÂ’do Lanza, et al. 2006) Accultura tion is the cultural adjustment or change that a group or individual experien ces when previously separate cultures interact with one another and is a multidimensional process that can result in many different outcomes on the individual level ( Berry 1997 ). Often this occurs when a

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! 2 minority (migrant or indigenous) culture interacts with a majority (host or colonial) culture I refer to the majority culture, in this study American, as the host culture and the minority culture, the Middle Eastern culture of the participant, as the heritage culture. T hi s p r oject examines the intra group differences of acculturation on an individual scale, and as such, the discussion will refer to individual concepts of acculturation Acculturation is often operationalized as either a uni dimensional or bi dimensional measur ement A uni dimensional model is one that interprets acculturation as a process where an individual changes from one cultural orientation to another, often moving from heritage to host cultural orientations ( Spindler, 1955 ). On the other hand, a bi dimensional model accounts for an individual's ability to identify with both host and heritage culture and does not conceptualize acculturation as a linear change from one culture to another ( McFee, 1968; Berry 1997 ) The study utilizes a bi dimensional mo del, which has been argued to provide more nuanced information about acculturation and its outcomes ( Fox et al., 2017 ) The conceptualization of acculturation has been inconsistent between studies in the social sciences and health and many studies do not clearly define their conceptualization One inconsistency in measurement pertains to temporality. While much research employs a current state status measure ( Berry, 2003 ), some studies of acculturation measure amount of cultural change (Rudmin, 2009). Though acculturation is a process of cultural change over time and using a change over time model could be beneficial to health research ( Fox et al., 2017 ), the study adopts a current state conceptualization as the stress measurements, both self reported a nd biomarker, represent a short period of time circa the survey. I also utilize a current state model because the participants in the study represent 1 st 2 nd and later generation individuals, and as such, all have different "acculturation intercepts," or starting points

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! 3 ( Castro et al., 2010; Lopez Class et al., 2011). Different acculturation intercepts influence how much cultural change an individual experiences over his or her lifetime and greater change may impact health more because there is a larger cu ltural distance that needs to be traversed (Fox et al., 2017). Because of the varied nativity of the participants, the study focused on an individual's current acculturation status and how it is related to stress levels during the same time period. O ne of the most common bi dimensional framework s used in modern acculturation research is Berry's four category model which splits an individual or group into either an integra ted, separated, assimilated, or marginalized category ( Berry, 1992 ). If an individual is considered integrated, then the person retains his or her heritage culture while gaining the culture of the majority. Separated individuals are those who id entify strongly with just t heir heritage culture but do not interact with the ho st culture whereas assimilated individuals are those who interact with host culture and do not maintain their heritage culture Finally, marginalized individuals are tho se who do not adopt or maintain either host or heritage c ulture. This conceptualizatio n of acculturation is bi dimensional, that is, it accounts for an individual's ability to identify and navigate with both, one or the ot her, or neither of the cultures and that the orientation to one culture does not reflect the orientation to another. Bec ause of the four category's bi di mensionality and popularity in acculturation research, this is the model that was chosen for this research project. 1.2 The Context Of Acculturation For Middle Eastern Americans Not only can a researcher's definition of acculturation affect interpretation and acculturation outcomes, but the social, political and cultural context within which acculturation occurs can have important impacts on the acculturative process The cultural

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! 4 adjustments that occur that is the changes to behaviors, beliefs, or identity that groups or individuals undergo are influenced by a number of socio cultural factors ( Fox et al., 2017 b ). While there are many different sociocultural factors to consider t hree that might influence acculturation in the present study are demographic makeup of the area in which people live, discrimination and difference be tween heritage and host culture ( Fox et al., 2017 b ). The type of immediate neighborhood that an individ ual is living in, whether predominately host (e.g. white American ) or predominately the heritage culture, can influence the acculturation trajectories (Castro, et al. 2010; Schwartz, et al. 2006). For example, some studies show that in Hispanic neighborhoo ds that are composed almost entirely of people sharing a heritage culture, individuals often do not have to go through many of the aspects of acculturation like learning the host country's customs or language ( Schwartz, et al. 2010 ). The neighborhood compo sition of the Denver and Boulder metro areas where the study was conducted is predominately white and Hispanic and Latino (US census data, 2010). This composition could likely have an effect on the different acculturation trajectories represented Discrim ination could either increase acculturation processes by encouraging an individual to beco me more like the host culture or by causing an individual to not participate in host cultural norms because of the unwelcoming and hostile environment of the host country (Fox et al., 2017 b ). A study by Te Lindert, et al. 2008 conducted in the Netherlands found that Iranian refugees retained their heritage cultura l orientation when there were higher levels of perceived discrimination and increased host cultural orientation when there was less perceived discrimination. Discrimination is also important to consider because many of the negative health effects like st ress and mental health issues, that researchers report from

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! 5 acculturation could in fact result from discrimination (Rudmin, 2009) Many Middle Eastern Americans experience discrimination in the United States, with notable increases occurring after the event of September 11 th ( Rousseau et al., 2011; Abu Ras and Abu Bader, 2008 ) and more recently, leading up to 2016 Presidential election ( FBI Statistics on Hate crimes, 2015 ; Levin 2016 ). This increase in discrimination when combined with the current p olitical climate in the United States could have a notable impact on MEAs acculturation trajectories and physical s tress levels. As such, it was important to address discrimination in the survey on acculturation trajectories. The difference between heritage and host culture may also greatly influence the acculturat ion trajectory of an individual, with greater cultural differences between the heritage and host culture causing more instances of stress and poorer health ( Fox et al., 2 017 b ). Young MEAs are positioned between two distinct, sometimes conflicting cultures, the Middle Eastern culture of their heritage and the Western American culture in which they live. One major source of conflict between American and Middle Eastern cultur es is when young MEA adults and their parents have different cultural values, with parents favoring more traditional values and children wishing to participate in Western society ( Haddad and Smith, 1996; Eisenlohr, 1996). This conflict reflects the notable differences between Middle Eastern and American cultures which may moderate the acculturation of MEA individuals. How young MEA adults respond to these discrepancies varies greatly between individuals (e.g. Ahmed, 2011; Gškarksel and McLarney, 2010; Bay oumi, 2008; Read and Bartkowski, 2000). First hand accounts of MEAs' experiences show that there are a variety of ways to respond to their unique cultural situation, with some young adults embracing or rejecting either the Western culture where they grew u p or the Middle Eastern culture of their parents

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! 6 Still others describe how they choose a middle road between the two (Bayoumi, 2008) reflecting a more integrated acculturation trajectory While the study does not directly address these issues of cultural discrepancies it is im portant to point out that these factors could h ave an e ffect on the acculturation trajectories of MEAs, especially considering the degree of difference between many MEAs cultures and the culture of the United States. 1.3 Acculturation and Health Recently, acculturation has become a topic of great interest in public health studies that seek to understand how acculturation could affect the health of an individual or group. Though there is little consistency across studies o f acculturation and health, most demonstrate some relationship between acculturation and the health of groups and individuals ( AbraÂ’do Lanza, et al. 2006) For example, assimilation has been found to be both a risk factor to various diseases like diabetes ( Stern et al., 1992 ) and low birth weight ( Cervantes et al., 1999 ), and a protective factor fo r health behaviors, like increased use of health services ( Clark, 2002 ) in Latino populations in America (Lara et al., 2005). The same could be said for studies examining acculturation and health in Asian American populations (Suinn, 2010). For example, high acculturation has been found to be a protective factor in Korean American men, but a risk factor in Korean American women ( Song et al., 2004 ). On the other h and, low ac culturation has been associated with psychological adjustment issues in Chinese and Taiwanese students ( Wang and Mallinckrodt, 2006 ). The effects of acculturation on health can be seen outside of the United States as well, a study examining cult ural consonance (the degree to which individuals approximate the beliefs and behaviors of their surrounding cultures) found that low cultural consonance was associated with high psychological distress in Brazil (Dressler et al., 2017). The discrepancies could be caused by

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! 7 a variety of issues from how acculturation is operationalized (Fox et al., 2017 a ), to not properly addressing cofactors and moderators of acculturation ( Fox et al., 2017 b ). However, what these studies highlight is that accu lturation does have an influence on the health of individuals albeit in context specific ways While w ork looking specifically at Arabic and Middle Eastern individuals has not been examined extensively, what has been done also shows that acculturation c an have differential effects on health. One study reported that a lack of assimilation in Arabic individuals who immigrated to the US was an important risk factor for diabetes (Jaber et al., 2003). Another found that Arabic Americans who reported moderate ethnic identity to both Arabic and American cultures that is those who were more integrated, had better self reported physical health, whereas individuals who were more assimilated reported better mental health (Jadalla and Lee, 2012). One last example de monstrated that Ara bic American individuals who were more separated reported better nutritional and stress management practices, whereas individuals who were more assimilated reported better physical activity and interpersonal relationships (Jadalla et al., 2015). These studies highlight how acculturation can affect health in Middle Eastern American communities in a variety of different ways and as such more work needs to be conducted to fully tease apart how acculturation impacts health in minority groups. One proposed way that acculturation can affect the health of an individual is through psychosocial stress, specifically what is termed "acculturative stress" (Berry and Annis, 1979; Berry et al., 1987) Acculturative stress is the stress that a person might experience when going through the process of acculturation and cultural change with those who experience more cultural change between differing cultures experiencing more acculturative

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! 8 stress ( Fox et al., 2017 b ; Berry and Annis, 1979) Acculturative stress may be t he cause of many of the negative health effects associated with acculturation For example, in a study examining depression symptoms in Mexican American pregnant women, acculturative stress defined as the amount of cultural c hange an individual experiences, and a mixture of Mexican and American values was associated with elevated depression symptoms (D'Anna Hernandez et al., 2015). Similarly a study found that in elderly Arabic individuals acculturative stress predicted depr ession (Howells Wrobel et al., 2009). While acculturative stress may have an effect on health outcomes, interestingly, research has generally shown that those who are integrated experience less stress than individuals who are assimilated or separated, and those in turn experience less stress than marginalized individuals (Berry, 2005). This relationship between acculturation strategies, acculturative stress and health needs to be further explored to fully understand the processes involved in the develop ment of adverse health outcomes 1. 4 Research G oals Elucidating the relationship between acculturation and stress will provide researchers and policy makers alike better knowledge on how to combat health issues that minorities and migrants face in the Uni ted States. As discussed above, p ast work has shown that acculturation can have an effect on perceived stress and mental health in minority populations (Nguyen and Benet MartÂ’nez 2013; Padilla, 2006). This study aims to add to our understanding of acculturation's effects on the health of minority and migrant populations. Specifically, I studied acculturation, perceived stress self esteem, depression and discrimination of young Middle Eastern American (MEA) students living in the Denver and Boulder metro areas. D ata were gathered on these factors through an online survey to

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! 9 describe and determine if there are any relationships between acculturation, perceived stress self esteem, depression and discrimination A cculturation has a positive impact on health in other minority populations in America, though results vary greatly ( Suinn 2010; Lara, et al. 2005 ). Possible explanations for this association are that individuals who are integrated in both their heritage culture and American culture can navigat e different social situations and also have larger support groups to rely on (Padilla, 2006). As such, I predict that integrated individuals will have the lowest levels of self reported stress the highest levels of self esteem and the lowest levels of d epression. I also predict that discrimination will have a mediating effect on acculturation category with individuals who experience higher discrimination being the least likely to be integrated. This project is novel in that it seeks to understand the relationship between acculturation and chronic stress among young MEA These aims will provide valuable insight into how the acculturation trajectories of young adults affect their physiological stress levels, which in turn can greatly impact their health. Young MEA adults are in a unique position, trying to find the balance between two, often conflicting cultures. Considering the current migration patterns of MEA individuals, and their growing role in American society, this project could offer topical insi ght into how young MEAs deal with integrating into both of their cultures. Finally, this project may have broader impacts for research on cultural identity in other minority groups in helping to elucidate the factors involved in acculturation and stress. T hese insights into acculturation and stress could further inform public policy directed towards increasing awareness of acculturation processes, decreasing stress, and improving the lives and health of multicultural individuals in the United States.

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! 10 CHAPT ER TWO METHODS 2.1 Recruitment Participants were recruited from the downtown Auraria campus in Denver and the University of Colorado, Boulder campus. Student organizations and interest groups were contacted and helped to disseminate information about the study to their members. Participants were also recruited in person by the researchers who attended student group meetings and events to talk about the project. Finally, flyers with information on the online survey were posted around both campuses. Particip ants were encouraged to share information about the research project and survey to their friends and family to facilitate snowball recruitment. Everyone who participated in the survey was entered to win one of five $20 visa gift cards and individuals who participated in the follow up study were compensated $10. 2.2 Participant Demographics Participants were between the ages of 18 35 and were livi ng in the Denver and Boulder areas. They were either first, second or third generation MEA adults. Complete data were available from 43 participa nts 2. 3 Survey M easures The survey was created through CU Denver's Redcap service. See appendix A for full survey. The survey included questions on basic demographic, perceived stress, self esteem, depression, discrimination and acculturation. The survey instruments used were established and validated by previous studies and included the Perceived Stress Scale (PSS) ( Cohen et

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! 11 al., 1983 ) the Rosenberg Self Esteem Scale (Rosenberg, 1965), the Everyday Discrimination Scale (Williams et al., 1997), the Center for Epidemiological Studies Depression Scale Revised (CESD R) (Radloff, 1997), and the General Ethnicity Q uestionnaire (GEQ) ( Tsai et al., 2000 ). The GEQ was the instrument chosen to measure acculturation and is a two part, 38 items per part survey that assesses both heritage and host cultural orientations. The questionnaire asks the same questions in both pa rts about behaviors, practices and language use for each culture (e.g. "I was raised in way that was American; I was raised in way that was Lebanese"). These items are scored on a 1 5 point Likert scale with 1 meaning "strongly disagree" to 5 meaning "stro ngly agree" for items pertaining to behavior and practice, and 1 meaning "very much" to 5 meaning "not at all" for language items. The GEQ was chosen as the instrument to measure acculturation because it is a bi dimensional scale, that is, it measures an i ndividual's cultural orientation for both the heritage and host cultures, allowing an individual to identify with both, one or the other, or neither. Another strength of the GEQ is its ability to be customized to the specific cultural group being studied. For this particular study, participants identified the cultural group they best identified with (e.g Lebanese, Saudi Arabian, Turkish, etc.) and this culture was then used in the heritage culture part of the GEQ. The survey also included questions that addressed possible confounding variable s Data were also collected on age, socioeconomic status, education level, 1 st 2 nd or 3 rd generation status (here defined as first generation are individuals who immigrated to the United States ) and religiosity. Li ke the survey instruments discussed above, the instruments used for confounding variables have also been validated by previous studies and include and the Duke University Religion Index (DUREL) ( Koenig and BŸssing, 2010 ). See Appendix A for a copy of the f ull survey.

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! 12 Perceived stress was scored by reverse coding the values of positively stated questions (i.e 0=4, 1=3, 2=2, 3=1, 4=0) and then summing the questions together (Cohen, 1983). Self esteem was scored by assigning 1 point for "strongly disagree" up to 4 for "strongly agree" and reverse scoring negatively phrased questions and su mming the scores for all items (Rosenberg, 1965) Discrimination was scored by assigning the value of 0 for responses of "never" up to 3 for responses of "often" and the ite ms were summed for an overall discrimination score (Williams et al., 1997). T he CESD R was scored by assigning 0 points from "not at all" up to 3 for "nearly every day" and then summing all items together with the higher score s representing more depressiv e feelings (Radloff, 1997). The cultural identity groups were scored by coding all the items the same and then calculating a mean of all the items for an overall cultural orientation score (Tsai et al., 2000). Participants were then classified into one of Berry's (1980) four acculturation categories : integrated, assimilated, separated, or marginal. Individuals who scored above the midpoint (i.e mean is higher than 2.5 on a 5 point scale) for both the heritage and American scales were coded as integrated; th ose who scored above the midpoint on the American scale but below the midpoint on the heritage scale were coded as assimilated; as follows: those who scored below the midpoint on the American scale but above the midpoint on the heritage scale were coded as separated; and those who coded below the midpoint on both the American and heritage scales were coded as marginal (Ying et al., 2000). 2. 4 Statistical A nalysis D escriptive statistics were used to determine the mean and standard deviation for perceived stress, self esteem, depression, discrimination and blood pressure. After calculating cultural orientation scores for heritage and host cultures, participants were sorted

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! 13 into integrated, assimil ated, separated, and marginal categories and the prevalence of each was assessed. Using these categories a one way ANOVA was performed to see if there were differences in average perceived stress levels between the four groups. D ifferences in average self esteem depression, and discrimination scores between the integrated, assimilated, separated and marginal groups were addressed by performing a separate t test for each group pairing. Partial correlations were run to determine if there was a relationship between heritage and host cultural identity scores and stress, self esteem, depression and discrimination. P .05 was used to indicate statistical significance and all statistics were run in IBM SPSS v. 24

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! 14 CHAPTER THREE RESULTS 3.1 Summary Statistics Of Population Characteristics The summary statistics for the study can be seen in Table 1. The study population included only in tegrated (n=3 5 ) and assimilated (n= 10 ) ind ividuals The average age was of the study sample was 23.1 years (std=4.4 years). Fo rty f ive percent of the study population was female, and there was one person who self identified as "other." Most pa rticipants were dependents (6 2 %), and mo st were first (3 8 %) and second (3 3 %) generation young adults. Summary statistics comparing the two acculturation categories are shown in table 2. Table 1: Summary statistics for population characteristics (standard deviations in parenthesis) Survey descriptive statistics Percentage/ mean N Female 45% 2 1 Male 53% 23 Other 2% 1 Dependent 62% 2 8 Independent 36% 16 Other financial 2% 1 1 st generation 38% 17 2 nd generation 33% 15 3 rd generation 29 % 13 Integrated 78% 35 Assimilated 22% 10 Age (mean) 23.1 (4.4) 45 Heritage COS (mean) 3.6 (.6) 45 US COS (mean) 3.9 (.3) 45 Perceived stress score (mean) 18.6 (6.1) 45 Self esteem score (mean) 20.7 (6.3) 45 Depression (mean) 17.3 (11.1) 45 Discrimination (mean) 1.7 (1.1) 45 Religiosity score (mean) 9.6 (3.7) 45

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! 15 Table 2 : Summary statistics for population characteristics comparing integrated and assimilated categories (standard deviations in parentheses). Integrated Assimilated n=3 5 n= 10 Age (average) 22.9 (4.3) 25.25(5.3) Female (n) 1 5 6 Male (n) 19 4 Other (sex) 1 0 Dependent (n) 2 1 7 Independent (n) 13 3 Other (financial) 1 0 1 st generation (n) 1 6 1 2 nd generation (n) 10 5 3 rd generation (n) 9 4 Heritage COS ( mean ) 3.9 (.4) 2.7(.3) US COS ( mean ) 3.9(.3) 4.0 (.1) Perceived stress score ( mean ) 17.0(5.4 ) 23.1(6 ) Self esteem score ( mean ) 19.8(6 .5) 24.4(4 ) Depression score ( mean ) 14.3(9.7 ) 29.0(9.8 ) Discrimination score ( mean ) 1.6(1.1 ) 1.8(.76 ) Religiosity score ( mean) 10.1(3.8 ) 7.3(2.8 ) 3.2 ANOVA Comparing Perceived Stress, Self Esteem, Depression, And Discrimination For Integrated And Assimilated Groups There was a significant difference between th e mean perceived stress score (F = 7.1; p= 01 ) the Rosenberg's self esteem score (F=4.3; p=.04) and the CESD R depression score (F=14.3; p<. 01) between groups with integrated individuals re porting lower levels of stress, self esteem and depression when compared to assimilated individuals. There was no significant difference (p=.8 ) between mean discr imination scores for integrated and assimilated individuals. Table 3 : ANOVA results for comparing means of PSS, self esteem, CESD R, and EDS between integrated and assimilated individuals P value F statistic Perceived stress <.01 7.1 Self esteem <.04 4.3

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! 16 Table 3 cont'd Depression <.01 14.3 3.3 Correlations Between Cultural Orientation Scores And Stress, Self Esteem, Depression, And Discrimination. There was a negative significant moderate correlation between a person's heritage cultural orientation sco re and perceived stress (r= .32 p=.0 5 ) and depression (r= .331, p= .05 ) (table 2). The US cultural orientation score only had one near significant, positive correlation with perceived stress (r=.308; p=.06 ). Discrimination was correlated wi th n either heritage n or US cultural orientation scores and only had a moderate, positive correlat ion with perceived stress (r=.342; p=.047) and depression (r=.329; p=.05) Table 4 : Correlations table for cultural identity scores and stress, self esteem, depression, and discrimination, controlling for religion, sex, financial status, generational status, and age. Heritage orientation Host orientation Perceived Stress Self esteem Depression Host orientation .212 Perceived stress .320* .308 Self esteem .227 .038 .161 Depression .331 .177 .766 ** .243 Discrimination .158 .14 .342 .035 .329* *p<.05, **p<.01

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! 17 CHAPTER FOUR DISCUSSION Public health research has become increasingly interested in acculturation and health, especially as the United States continues to become more diverse and multicultural ( AbraÂ’do Lanza, et al. 2006). The study aimed to further pick apart the relationship between acculturation and mental health in Middle Eastern Americans by exam in ing survey data on acculturation, stress, self esteem, and depression. The results show that there is clearly a relationship between acculturation trajectories of Middle Eastern A mericans and their psychological outcomes. We found that integrated individuals had lower levels of stress, depression and self esteem whereas assimilated individuals all had higher levels of stress, depression and self esteem. T hese results are discussed in depth below as well as, possible future directions acculturation research can take. The results of the one way ANOVA partially supported my hypotheses. Integrated individuals had significantly lower stress and depression levels than ass imilated individuals. These results support past research and demonstrate that being integrated can have a positive impact on an individual s health (e.g. Padilla, 2006 ). Identifying with both an individual's host and heritage culture has a protective effe ct on stress and depression. This protective nature of integration is likely due to the increase in social support in both the public (friends) and private (family) spheres. It may be also be related to a decrease in stressful cultural interactions between an individual and the two cultural environments they have to navigate. However, assimilated individuals had, on average, higher levels of self esteem than their integrated counterparts. This relationship has been re ported in some previous research on acculturation and self esteem (Meyer et al., 2005), though other studies support the initial

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! 18 hypothesis that integrated individuals would have the best self reported psychological outcomes (Vasquez et al., 2011). The re sults of the partial correlations further highlight the unexpected relationship between heritage culture and self esteem The heritage cultural orientation score was negatively associated with all three psychological measures (though weak and non significa nt for self esteem p=.18 ) meaning that as heritage orientation increases, stress, depression and self esteem all decrease. T he reported relationship was expected for stress and depression and supports the ANOVA results. T he lack of significant findings and the negative correlation for self esteem was surprising, though is reflected in the ANOVA results discussed above. Assimilated individuals (those that report low heritage cultural orientation) have higher levels of self esteem on average compared to integrated individuals (those with higher heritage scores). A number of factors could be influencing this relationship, such as host and heritage cultural values. American culture tends to emphasize the individual and individu al rights (Hong et al., 2001). Many Middle Eastern cultures, on the other hand, emphasize family relationships and duties (Haddad and Smith, 1996; Kulwicki, 1996). These differences in cultural values may influence a person's self esteem and depression dep ending on which cultural values are adopted. For example, an assimilated individual may adopt the American value of individualism, which would positively affect their self est eem, while deemphasizing familial support, which may contribute to depression. Ot her studies reported similar results between acculturation and self esteem particularly in Hispanic populations (e.g. Meyer et al. 2005; Flaskerud and Uman 1996 ) though these studies do not discuss self esteem as a cultural value. Exploring this idea of self esteem as a cultural value would be useful for future research on acculturation.

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! 19 Depression and stress followed the expected pattern and were positively correlated to one another (Hammen, 2005). However, self esteem was positiv ely correlated to both perceived stress and depression (though again non significant p=.1 and p=.15, respectively ) meaning the higher an individual's self esteem score, the higher that person's stress and depression scores are as well. These results are contrary to past findings on the relationship between self esteem depression, and stress which demonstrate that higher self esteem protects against depression and stress (Moksnes et al., 2016; Orth and Robins, 2013). Self esteem's positive relationships with these two outcomes may reflect how influential acculturation can be on mental health outcomes. These results further emphasize the importance of continuing acculturation research to fully pick apart these complex relationships. P artial correlations were also run to see how the continuous cultural orientation scores were related if at all There was a weak though non significant (p=.062), negative correlation between US cultural orientation score and the heritage cultural orientation score. This ma y be related to the study population, which includes first, second, and third generation young adults The int egrated group is composed of 44 % first generation adults wher eas the assimilated group was 44 % third generation or later. This spread of first, se cond, and third generation students could have an effect on how the cultural orientation scores interact as these individuals all have different acculturation intercepts or cultural starting points ( Castro et al., 2010; Lopez Class et al., 2011). Third generation individuals may have higher US orientation scores coupled with lower heritage cultural orientation scores because their starting point of acculturation is more engrained in US culture than their heritage culture

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! 20 While generation status m ay have a slight effect on acculturation trajectories it is still not a good proxy to use in lieu of direct acculturative measures. In order to test this, I ran one way ANOVA to see if a different generation status affected stress, depression, and self es teem. I found that there was no signific ant difference between gen eration status and stress (F=.93, p=.4 ) and depress ion (F=1.03, p=.36 ) though there was a signifigant effect on self esteem (F= 3.8 p=. 03 ) whereas accultur ation status had a signific ant effect on all three measures. This suggests that generation s tatus is a poor substitution for validated acculturation measures. Future research on acculturation should strive to include not only generational status, but also direct acculturative measures l ike values, beliefs, behaviors, and actions ( Fox et al., 2017b ). T he US cultural orientation score was not significantly correlated to any of the psychological measures, but there was a moderate, positive non significant (p=.08 ) correlation with perceived stress. The increase in perceived stress that highly acculturated individuals experience could be related to a number of things. One possible factor as described above could be an individual's acculturation intercept. If an individual has a lon g cultural distance to traverse, like f irst generation individuals, the n the amount of acculturative stress they experience may be higher which could be reflected in their perceived stress scores (Fox et al., 2017 b ). Another possible factor is the cultural context of the host culture For example, Americans report some of the high est everyday stress levels (i.e. work, day to day life stressors) in the world ( American Psychological Association ) and individuals who have higher perceived stress scores may be reflecting that aspect of American culture. Future research on acculturation should take an individual's cultural starting point perhaps indexed by a retrospective survey or data on place of birth and number of locations lived into

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! 21 account. It wo uld also be useful to collect qualitative data on what the heritage and host cultures' opinions or views are on the psychological measures being tested. For example, what are the perceived cultural differences related to the value of self esteem between th e host and heritage culture ? The vast majority of participants were integrated individuals (79%). The remaining 21% of the sample were assimilated, and there were no separated or marginal individuals. This distribution was likely influenced by the locati on of the study population, which was recruited from the CU Denver and Boulder campuses. As discussed above, the composition of an individual's neighborhood likely has an effect on acculturation trajectories (Castro, et al. 2010; Schwartz, et al. 2006). The neighborhoods of Denver and Boulder are predominantly white and Hispanic (US Census Data, 2010). This composition likely increased the number of interactions that MEAs had with the host culture and, in turn, influenced the population's acculturation t rajectories. Though the study does not directly address this issue, it is important to note that it is probable the neighborhood composition of Denver and Boulder contributed to the study's lack of separated or marginalized individuals. One result that was unexpected was the lack of effect that discrimination had on acculturation and cultural identity scores. I had hypothesize d that discrimination would influence the acculturation trajectories of participants yet in the results I do not see this occurring This may be due to the a cculturation composition of the participants, which represent only integra ted and assimilated individuals. These individuals may not experience discrimination in the same way a separated or marginal person might. High levels of dis crimination have been shown to discourage acculturation in some populations ( Fox et al., 2017b; Te Lindert, et al. 2008 ), and the same may be true for Middle Eastern Americans who

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! 22 are separated or marginal. The average discrimination score of the participants was 1. 7 (on a 0 5 scale) which represents a rela tively low discrimination score (Williams et al., 1997). The very low discrimination score may be attributed to the political and social make up of the D enver and Boulder areas, which are generally very liberal, and future work should address this unexpected result. Regardless, low discrimination score could be contributing to the acculturation trajectories seen in the present study. Discrimination could still be having an effect on acculturation, however the study may not have enough variation in discrimination experience to see these effects One limitation of the study is the small sample size, which most likely contributed to only two acculturation ca tegories being represented. Despite this limi t ation, I w as able to partially support the hypothesis that integrated individuals have lower levels of stress and depression and I found significant relationships between heritage cultural orientation an d the dependent variables. These data highlight many new possibilities for futur e research on acculturation. One area that the research highlights is the need for more work examining the relationship between acculturation and self esteem. As discussed above, the results that were found were unexpected and future work should explore f actors such as acculturation int ercepts and overall cultural v alues should be explored in greater detail. Yet another interesting finding is how strong of a mitigating effect accul turation might be having on the relationship between self esteem, stress and depression. An important avenue for future research on acculturation and health is the collection of biomarker data collection. Biomarker data on stress can give a physical measu re of stress along with the perceived measures from survey. For example, b lood pressure is an established measure for higher chronic stress levels (Sweet, 2001; Gravlee and Dressler

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! 23 2005; Juster et al., 2010). Higher levels of chronic stress are associate d with an increased risk of cardiovascular disease, likely through the activation of the sympathetic adrenal medullary (SAM) axis and the hypothalamic pituitary adrenal (HPA) axis which elicit a "fight or flight" response to stress (Sapolsky et al., 2000). This fight or flight reaction increases heart rate and vasoconstriction, which can lead to hypertension (Ayada et al., 2015). Cortisol is another useful biomarker of stress. It is a glucocorticoid produced in the adrenal cortex that increases when an individual experiences greater stress (Pollard and Ice, 2006). Hair cortisol is particularly good for measuring overall elevated levels of cortisol overtime (typically representing chronic stress over one to two months), and is not sensitive to diurnal var iation making it a more reliable index of HPA axis function when only a single measurement can be taken (Russell et al., 2010; SauvÂŽ et al., 2007). Hair cortisol like blood pressure, is a relatively easy, non invasive measurement to collect from participa nts and would greatly add to the understanding of stress and acculturation. The United States is becoming an increasingly diverse a nd multicultural environment. T he process of acculturation will therefore continue to be of interest to public health resear chers and policy makers. The study demonstrates how influential acculturation can be on an individual's stress, self esteem and depression while drawing attention to many vital future research p aths Integrated individuals demonst rated that there are advantages of being oriented to both host and heritage culture for stress and depression, but not for self esteem. These results emphasize how important it is to conduct more research on acculturation and psychological outcomes, particularly self esteem. The study also provides evidence against the use of proxies for acculturation research, as the proxy, generational status, did not

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! 24 produce significant results like the direct acculturation measure did. Future work on acculturation and health would benefit from direct acculturative measures as well as, direct biological measures. These data can help to improve the public health of minority and immigrant groups throughout the United States by demonstrating both the positive and negative effects of acculturati on on mental and physical health. Policy makers and public health officials could use the present data and future research avenues discussed in this article to inform the public and improve the lives of multicultural individuals.

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! 25 REFERENCES AbraÂ’do Lanza, AF, Armbrist er, AN, et al. 2006 Toward a theory driven model of acculturation in public health research. Am J Public Health, 96: 1342 1346. Abu Ras W, Abu Bader S. 2008. The impact of the September 11, 2001 attacks on the well being of Ara b Americans in New York City. J Muslim Ment Health 3(2): 217 239. Ahmed L. 2011. A Quiet Revolution: The Veil's Resurgence, from the Middle East to America. New Haven: Yale University Press. Amer ican Psychological Association. 2016 Stress in America: The impact of discrimination. Stress in America Survey Bayoumi M. 2008. How Does it Feel to be a Problem? New York, NY: The Penguin Press. Berry, JW. 1997 Immigration, acculturation, and adaptation. Applied psychology, 46: 5 34. Berry, JW, and RC An nis. 1974 Acculturative stress: the role of ecology, culture and differentiation. Journal of cross cultural psychology 5(4):382 406. Berry, JW, et al. 1987 Comparative studies of acculturative stress. International migration review 21(3):491 511. Berry JW, et al. 1987 Comparative studies of acculturative stress. International migration review 21(3):491 511. Berry, JW. 2003 Conceptual approaches to acculturation. In KM Chun, P Balls Organista, et al. (Eds.), Acculturation: Advances in theory, measure ment, and applied research pp. 17 37): American Psychological Association Berry, JW. 1992 Acculturation and adaptation in a new society. International migration 30(s1):69 85. Boas, F. 1888 The aims of ethnology. In F Boas (Ed.), Race, language, and cul ture pp. 628 638). New York: Macmillan. Castro, FG, et al. 2010 Lifetime segmented assimilation trajectories and health outcomes in Latino and other community residents. Am. J. Public Health 100(4):669. Cervantes A, Keith L, Wyshak G. 1999. Adverse birth outcomes among native born and immigrant women: replicating national evidence regarding Mexicans at the local level. Matern. Child Health J. 3(2):99 109.

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! 26 Clark L. 2002. Mexican origin mothers' experiences using children's health care services. West. J. N urs. Res. 24(2):159 79. Cohen, S., Kamarck, T, and Mermelstein, R. 1983. A Glob al Measure of Perceived Stress. Journal of Health and Social Behavior, 24( 4), Appendix A. D'Anna Hernandez, KL, B Aleman, and A M Flores. 2015. Acculturative stress negatively impacts maternal depressive symptoms in Mexican American women during pregnancy. J. Affect. Disord. 176:35 42 Dressler WW, Balieiro MC and dos Santos JE. 2017. Cultural Consonance in Life Goals and Depressive Symptoms in Urban Brazil. Journal of Anthropological Research 73 (1). Eisenlohr CJ. 1996. Adolescent Arab Girls in an American High School. In: Aswad B, Bilge B, editors. Family and Gender Among American Muslims. Philadelphia: Temple University Press. 250 270. Flaskerud JH and Uman G. 1996. Acculturation and its effects on self esteem among immigrant Latina women. Behavioral Medicine 22 (3): 123 133. Fox et al., 2017a. Conceptualization and operationalization of the construct of acculturation in minority health research. Social Science & Medicine. In press. Fox et al., 2017b. Acculturation and health: the moderating role of socio cultural context. American Anthropologist. In press. Gškarksel B and McLarney E. 2010. Muslim Women, Consumer Capitalism, and the Islamic Culture Industr y. Journal of Middle East Women's Studies 6(3):1 18. Gravlee CC and Dressler WW. 2005 Skin pigmentation, self perceived color, and arterial blood pressure in Puerto Rico. American Journal of Human Biology. 17(2):195 206. Haddad YY and Smith JI. 1996. "Islamic Values Among American Muslims." In: Aswad B, Bilge B, editors. Family and Gender Among American Muslims. Philadelph ia: Temple University Press. 19 40. Hammen, C., 2005. Stress and depression. Annu. Rev. Clin. Psychol., 1: 293 319. Hong, Y.Y., Ip, G., Chiu, C.Y., Morris, M.W. and Menon, T., 2001. Cultural identity and dynamic construction of the self: Collective duties and individual rights in Chinese and American cultures. Social Cognition, 19(3): 251 268. Jaber, L.A., Brown, M.B., Hammad, A., Zhu, Q. and Herman, W.H., 2003. Lack of acculturation is a risk factor for diabetes in Arab immigrants in the US. Diabetes Care 26 (7), pp.2010 2014.

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