Acculturation, Mental Health, and Wellbeing Among Hispanic/Latinx Young Adult Survivors of Childhood Cancer

Abstract

Purpose:

Ethnic disparities in childhood cancer survivor (CCS) mental health have been identified, although prior survivorship research has focused predominantly on non-Hispanic/Latinx (H/L) white survivors.

Methods:

This study examined the association of acculturation with depressive symptoms and wellbeing among 582 young adult H/L CCS recruited to a population-based study of CCS in Southern California.

Results:

In multivariable regression models adjusted for covariates, greater identification with both the Hispanic and Anglo cultures was positively associated with wellbeing (p = 0.007 and p < 0.0001, respectively), and Hispanic cultural identification was associated with fewer depressive symptoms (p = 0.04).

Conclusions:

Greater understanding of unique protective factors among minority CCS may inform tailored interventions promoting mental health.

Introduction

While survival has improved in recent decades for childhood cancer survivors (CCS), morbidity remains a prominent issue. About 75% of CCS will develop a late effect (cancer treatment-related sequelae) in adulthood.¹ In addition to physical health issues, mental health issues may arise as a consequence of ongoing health problems and/or a lack of support, which may adversely impact quality of life.^2,3

Despite representing a rapidly growing minority group in the United States, Hispanic/Latinx (H/L) individuals have been underrepresented in much of the CCS literature. Moreover, diverse H/L populations are often grouped together, obscuring subgroup variation. Investigation of cultural factors may provide further insight into unique risk and protective factors among H/L CCS. Acculturation—the multidimensional process of adapting to a new culture—entails identification toward one's heritage culture and the receiving culture they or their families migrated into, and may impact CCS health status through various pathways.⁴ In a pilot study of young adult CCS, H/L reported greater depressive symptoms than non-H/L, and identification with the United States culture among H/L was associated with more reported symptoms.³ Conversely, greater identification with the receiving culture may be protective due to reduced discrimination and associated chronic stress, as discrimination is associated with poorer self-rated health and depression among (non-CCS) H/L in the United States.^5,6 While the relationships between acculturation and depressive symptoms and wellbeing have predominantly focused on noncancer populations, similar mechanisms may be salient among CCS and warrant further investigation.

This study assessed the relationships between acculturation and depressive symptoms and wellbeing among a population-based sample of H/L CCS. Based on prior findings, it was hypothesized that identification with both the United States/Anglo and Hispanic cultures would be associated with fewer depressive symptoms and greater wellbeing. Exploratory analyses also assessed potential interactions between cultural identification and age at diagnosis.

Methods

Participants

Participants were recruited to the Project Forward Cohort, a population-based study of health care use and health among CCS. Eligible CCS were recruited from the Los Angeles Cancer Surveillance Program, the Surveillance, Epidemiology, and End Results (SEER) cancer registry for Los Angeles County. CCS were eligible if they were diagnosed at age 19 or younger and were between the ages of 18 and 39 at the time of study initiation in 2015. Analyses were restricted to participants who self-identified as H/L and had been off cancer treatment for at least 2 years.

Procedures

Surveys were completed either in English or Spanish, with the option to complete it on paper, online, over the phone, or in person. Participant compensation included $20 cash and entry into a lottery for a $300 prize. Procedures were approved by the California Committee for the Protection of Human Subjects, California Cancer Registry, and human subjects committee at the University of Southern California.

Measures

Demographic information, including age, sex, and age at diagnosis was obtained from the cancer registry. Ethnicity and education were self-reported. Nativity (United States vs. foreign-born) was self-reported and is reported, but was not included in multivariable models due to high collinearity with the acculturation subscales.

Treatment intensity

Treatment intensity was estimated for each case using cancer registry data in combination with self-report data using a novel method based on the approach defined in the Intensity of Treatment Rating Scale 3.0 (ITR-3), which uses clinical and treatment information to categorize four levels of treatment intensity (1 = least intensive [e.g., surgery only], 2 = moderately intensive [e.g., chemotherapy or radiation], 3 = very intensive [e.g., 2+ treatment modalities], and 4 = most intensive [e.g., relapse protocols]).^7,8

Acculturation

Participants self-identifying as H/L responded to a 13-item measure of acculturation, adapted from the Acculturation Rating Scale for Mexican Americans-II.⁹ Questions comprised two subscales, one for each culture (H/L and Anglo), based on the conceptualization of acculturation as a bidimensional process where receiving-culture acquisition and heritage-culture retention reflect distinct dimensions that are not mutually exclusive.¹⁰ This adapted scale included items focused predominantly on linguistic preference and behavioral aspects of acculturation. The full scale is available in Appendix Table A1. Items reflective of H/L identification referred to Spanish but not to a specific country, and thus were inclusive of all Spanish-speaking H/L countries of origin. Possible responses range from 1 (“Not at all”) to 5 (“Almost always/extremely often”). Subscale scores were summed, ranging from 6–30 for the Hispanic subscale (based on six items) and 6–35 for the Anglo subscale (based on seven items), where higher scores represent greater identification with that culture. Cronbach's alpha for Hispanic and Anglo orientation subscales were 0.92 and 0.71, respectively.

Depressive symptoms

The Center for Epidemiologic Studies Depression (CES-D) Scale was used to assess past week depressive symptoms as a measure of mental health.¹¹ This scale includes 20 items about how often participants experienced symptoms in the past week, such as depressed mood, sleep disruption, and feelings of hopelessness. Possible response options range from 0—“Rarely/none of the time” to 3—“Most or all of the time.” For analyses, scores were summed across items with a possible range of 0–60, where higher scores represent greater symptomology. Cronbach's alpha was 0.91.

Wellbeing

Wellbeing was assessed using the 14-item Mental Health Continuum-Short Form, chosen for its brevity, validity, reliability, and comprehensiveness.¹² Participants were asked to indicate how often in the past month they felt a certain way, such as “interested in life,” “that you belonged to a community,” “good at managing the responsibilities of your daily life,” or “that your life has a sense of direction or meaning to it.” Response options ranged from 0—“Never” to 5—“Every day.” For analyses, scores were summed across items with a possible range of 0–70, where higher scores represent greater wellbeing. Cronbach's alpha was 0.94.

Statistical analysis

Depressive symptoms and wellbeing were modeled using multivariable linear regression. Both unadjusted and adjusted associations were assessed. The H/L and Anglo subscales were included as distinct independent variables to explore their unique associations with each outcome. The following covariates were controlled for, based on previously reported associations in the literature: sex, age at diagnosis, current age, treatment intensity, and education (as a proxy for individual socioeconomic status).^13,14 All covariates were modeled as continuous variables, except for sex. The interaction between Hispanic and Anglo identification and age at diagnosis was also assessed in exploratory models to evaluate potential effect modification. Multivariable models were weighted to account for survey nonresponse bias using propensity score weights, and standard errors were clustered by diagnosing hospital. All analyses were conducted using SAS statistical software (Version 9.4) (SAS Institute, Cary, North Carolina, USA).

Results

The complete analytic sample consisted of 582 H/L CCS, roughly half female with a mean age at diagnosis of 11.4, a mean age at survey of 25.8, and 11% foreign born. Complete descriptive statistics are presented in Table 1. No significant differences were observed between those with missing and nonmissing data for depressive symptoms and the Hispanic identification subscale. However, missingness for the wellbeing scale and Anglo identification differed by education, where those with higher education levels were less likely to be missing these items (p's < 0.05). However, given that this association with missingness was not observed uniformly across correlated items, we do not believe this to be reflective of an underlying trend.

Table 1.

Sample Descriptive Statistics, N = 582 Overall

	N (%)	N missing (%)
Female	307 (53.0)	0 (0.0)
Treatment intensity
Least intensive	15 (2.6)	0 (0.0)
Moderately intensive	198 (34.0)
Very intensive	293 (50.0)
Most intensive	76 (13.0)
Cancer site group		0 (0.0)
Leukemia	233 (40.0)
Lymphoma	117 (20.0)
Brain/other nervous system	68 (12.0)
Endocrine	37 (6.4)
Skin	4 (0.7)
Other	123 (21.0)
Education	3 (0.5)	0 (0.0)
Grade school	38 (6.5)
Some high school	134 (23.0)
High school graduate/GED	244 (41.9)
Some college/training	52 (8.9)
Associate degree	91 (15.6)
College graduate	20 (3.4)
Postgraduate degree

	Mean (SD), observed range	N missing (%)
Age at diagnosis	11.4 (5.4), 0–19	0 (0.0)
Age at survey	25.8 (4.7), 18–41	0 (0.0)
Years since diagnosis	14.4 (4.5), 5–22	0 (0.0)
Wellbeinga	46.7 (15.1), 4–70	35 (6.0)
Depressive symptoms	14.5 (11.0), 0–58	51 (8.8)
Acculturation	—
Hispanic orientation	18.6 (6.6), 6–30	19 (3.3)
Anglo orientation	29.4 (3.9), 12–35	25 (4.3)

^a Mental Health Continuum sum score.

GED, General Educational Development (high school equivalency); SD, standard deviation.

Depressive symptoms

In unadjusted analyses, greater H/L identification and education were associated with fewer depressive symptoms. These associations remained significant in the multivariable model adjusted for covariates (Table 2). In exploratory analyses, no significant interactions were observed between Hispanic and Anglo identification and age at diagnosis.

Table 2.

Unadjusted and Adjusted Associations With Depressive Symptoms (Center for Epidemiologic Studies Depression Sum Score) (Adjusted Model, n = 501)

	Unadjusted associations		Adjusted associations
	Estimate (SE)	p	Estimate (SE)	p
Hispanic identification	−0.12 (0.07)	0.09	−0.14 (0.07)	0.04
Anglo identification	−0.13 (0.13)	0.31	−0.10 (0.09)	0.26
Female	−0.38 (0.95)	0.69	−0.16 (0.71)	0.82
Age at diagnosis	0.03 (0.09)	0.73	0.03 (0.11)	0.78
Age at survey	−0.11 (0.10)	0.28	−0.09 (0.14)	0.54
Treatment intensity	0.26 (0.67)	0.69	0.43 (0.45)	0.34
Education	−1.05 (0.38)	0.006	−0.91 (0.36)	0.02

SE, standard error.

Wellbeing

In unadjusted analyses, greater Hispanic and Anglo identification, female gender, age at diagnosis, and education were associated with greater wellbeing (Table 3). The age at diagnosis association was attenuated in the adjusted model, but all other associations remained significant after adjusting for covariates. In exploratory analyses (not shown in tables), a significant positive interaction was observed between Hispanic identification and age at diagnosis (p = 0.002). For those diagnosed at older ages, Hispanic cultural identification was more strongly associated with greater wellbeing.

Table 3.

Unadjusted and Adjusted Associations with Wellbeing (Mental Health Continuum Sum Score) (Adjusted Model, n = 517)

	Unadjusted associations		Adjusted associations
	Estimate (SE)	p	Estimate (SE)	p
Hispanic identification	0.25 (0.10)	0.01	0.29 (0.10)	0.007
Anglo identification	0.65 (0.17)	<0.001	0.70 (0.09)	<0.001
Female	2.27 (1.29)	0.08	2.12 (0.68)	0.004
Age at diagnosis	0.27 (0.12)	0.02	0.23 (0.15)	0.14
Age at survey	0.21 (0.14)	0.12	−0.01 (0.14)	0.93
Treatment intensity	−1.42 (0.91)	0.12	−1.62 (1.26)	0.21
Education	1.92 (0.52)	<0.001	1.04 (0.41)	0.01

Discussion

Leveraging a population-based sample of H/L CCS, we found that Hispanic identification was associated with greater wellbeing and fewer depressive symptoms, consistent with our hypotheses and prior work. This may be attributed to values that promote positive, close family relationships and support, which have been previously associated with improved mental health among H/L in the United States.^15–17 Additionally, retention of heritage culture has been associated (in the general population) with greater self-esteem, self-efficacy, positive coping, and feelings of belonging, and fewer internalizing symptoms.^18,19

Interventions to promote family functioning and the preservation of protective values may be valuable, especially in the context of recovery from a complex childhood disease. Such interventions might help CCS and their families form shared goals and enhance communication to integrate cultural values into coping strategies. This may be particularly valuable during the transition from the pediatric oncology setting to adult survivorship care, a time which must include adequate support for CCS to ensure they are equipped with the knowledge and skills to self-manage their long-term health.²⁰ Maintaining family involvement, without impacting gains in CCS independence, may help facilitate navigation of complex health care changes, such as altered insurance status or finding a new health care provider.

We found that Anglo identification was associated with greater wellbeing, consistent with our hypothesis. Moreover, exploratory analyses revealed that CCS diagnosed at older ages may experience a stronger protective benefit of Hispanic cultural identification on wellbeing. This association may be due to a range of possible factors, including increased social connectedness and improved self-esteem.^21,22 For example, CCS diagnosed as teens may be more engaged in monitoring and managing their health and cancer-related follow-up care as adults compared with their peers who were diagnosed as very young children. For these older diagnoses, stronger identification with the United States' culture may signify a greater understanding of, and/or access to the health care system and available resources that support survivor wellbeing.

Adoption of and identification with the United States/Anglo culture may also lead to reduced perceived discrimination, which has been associated with greater wellbeing through social cohesion and personal resilience.²³ However, the positive association between Anglo identification and wellbeing should be taken not to suggest an onus on minority survivors to assimilate, but rather a responsibility of broader health and social systems to prioritize equitable treatment and inclusion of all individuals. In the context of survivorship clinics and programs, CCS wellbeing may be enhanced by connecting survivors with one another through virtual or in-person social support groups, with attention to accessibility for cultural and linguistic minorities.

Our findings are limited by the cross-sectional nature of the data, precluding causal inference. Although culturally based differences may have impacted the interpretation of survey questions by participants, measurement properties of the CES-D among H/L adults in the United States have shown acceptable consistency across subgroups, suggesting that differences in scores likely reflect actual differences in symptoms.²⁴ Additionally, brief measures of acculturation cannot definitively capture the full nuance and complexity of culture.²⁵ More detailed measures of values, beliefs, preferences, and practices are needed to further disentangle cultural factors that promote resiliency among young adult H/L CCS in the United States. However, although limited in its measurement, acculturation is one means of examining heterogeneity within minority CCS rather than assuming homogeneity, which contributes to increased research and insight into the need for tailored support services for CCS that leverage a range of beneficial resources.

This study provides insight into correlates of depressive symptoms and wellbeing among H/L CCS, who have been underrepresented in prior survivorship research despite the rapid growth of this population in the United States. The ability of this study to recruit a diverse sample from the state with the largest number of H/L in the country, while also characterizing individual-level acculturation, represents an important contribution to the field of cancer disparities research.

Hispanic and Anglo cultural identification may be protective of depressive symptoms and wellbeing among H/L CCS. Specific values and practices underlying these protective effects should be explored in future work, such as the strength of family relationships and support. Such health-protective factors could be the target of family-based interventions aimed at improving health outcomes in young adult Hispanic CCS.

Appendix

Appendix Table A1.

Acculturation Items Measured Among Respondents Self-Identifying as Hispanic/Latinx

Disclaimer

The contents do not represent the views of the United States Department of Veterans Affairs or the United States Government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by 1R01MD007801 from the National Institute on Minority Health and Health Disparities of the National Institutes of Health, with additional support from the National Cancer Institute (P30CA014089; T32CA009492). Dr. Tobin was supported by the VA Office of Academic Affiliations through the Advanced Fellowship Program in Health Services Research and Development.