Examining the Impact of the Cultural Gap Narrative on Family Functioning and Youth Substance Use among the Health Study/Study of Latino Youth (HCHS/SOL Youth) population

Abstract

The acculturation gap theory provides a complex illustration of how cultural orientations affect health behaviors among adolescents, by assuming that familial cultural orientation gaps lead to compromised family functioning and children adopting negative health behaviors. This analysis used three methods to conceptualize cultural gaps to examine the relationships between familial cultural orientation gaps and family functioning and substance use susceptibility among the Hispanic Community Children’s Health Study/Study of Hispanic/Latino Youth population. Results did not support the assumptions behind the acculturation gap theory. The methods used to conceptualize cultural gaps did not illustrate consistent underlying trends when measuring the relationship between cultural gaps and substance use susceptibility. There was no evidence of mediation on substance use susceptibility by perceived family functioning for either cultural domains using each method. This analysis underscores the need to refine the framework behind the acculturation gap theory and how cultural gaps are measured among Hispanic/Latino youth.

INTRODUCTION

Teenage substance use behavior continues to be a public health concern due its long-term health consequences. Adolescent smoking predicts chronic conditions such as impaired lung function and early abdominal aortic atherosclerosis disease [1]. Additionally, early alcohol use has been linked to higher prevalence of alcohol use disorders in middle adulthood [2], suicidal ideation [3], and accidents or injuries [4].

According to several national youth health surveys, Hispanic/Latino youth consistently report high rates of alcohol and tobacco use compared to their non-Hispanic/Latino counterparts. The 2017 National Youth Tobacco Survey estimated 5.3 percent of Hispanic/Latino middle school students had used a combustible tobacco product in the past 30 days, compared to 2.4 percent of White students and 3.9 percent of Black students [5]. This estimated prevalence increases in high school, doubling among Hispanic/Latino high students to nearly 12 percent, compared to 10.9 percent among Black students. The Monitoring the Future Study found that in 2011 almost one in three (31%) of Hispanic/Latino 12^th graders reported drinking alcohol in the past 30 days [2], and 65 percent Hispanic/Latino youth participating in the 2017 Youth Risk Behavior Survey reported having ever drunk alcohol, 20 percent higher than Black (51%) students [6]. A previous study of substance use among the Hispanic Community Children’s Health Study/Study of Latino Youth (HCHS/SOL Youth) population (ages 8-16) found that 19 percent of the population had ever consumed alcohol and 8.6 percent had ever tried smoking [7]. Moreover, 40 percent and 20 percent of HCHS/SOL Youth participants indicated they were susceptible to future use of alcohol and cigarettes respectively [7].

THEORETICAL FRAMEWORK

Epidemiologic studies indicate that immigrants from Latin America are substantially less likely to meet criteria for substance use disorder compared to Hispanics/Latinos born in the U.S. [8,9], causing researchers to question how the process of acculturation impacts adolescent substance use among Hispanics/Latinos [10]. While there is some evidence acculturation, specifically assimilation into U.S. culture, tends to negatively affect health, this relationship is very complex and still not well understood [10-12].

The acculturation gap theory attempts to provide a more complex illustration of how cultural orientations affect health behaviors among adolescents. The theory argues that the main reason children from immigrant families adopt negative health behaviors is not only due to gaps in acculturation between children and parents, but it is mediated by overall family functioning [13,14]. The unique impact of cultural conflict on adolescent health in immigrant Hispanic/Latino households has been previously studied. Some studies have found evidence supporting the acculturation gap theory, showing that among Hispanics/Latinos, parental-child acculturation conflict is associated with increased symptoms of depression [15-17], trends in substance use [18-21], academic performance [18], and general health risk behaviors [16]. However, not all studies have found that negative behaviors were mediated by or independently associated with family functioning [15,16]. Furthermore, other studies have concluded that differences in acculturation between caregivers and children were unrelated or only modestly related to youth problem behaviors [22,23].

It is difficult to compare studies examining the acculturation gap theory because of inconsistencies with how cultural gaps are measured [14,24]. There are three main methods for calculating cultural gaps: (1) using an interaction term in a model to conceptualize the effect of the interaction of the caregiver’s and child’s cultural orientations on an outcome (interaction method); (2) grouping parents and children based on whether their levels of cultural orientations match or not (match/mismatch method); or (3) subtracting parents’ and children’s cultural orientation scores (difference method). The difference and match/mismatch method similarly conceptualize gaps by determining whether there is a discrepancy in orientations regardless of the direction of the difference and type of cultural discrepancies [14,24]. The interaction method has been identified as a more comprehensive method that accounts for the effect of the independent contributions of youth and parent cultural orientations as well as the direction and type of cultural discrepancies [14,24-26].

The main goal of this study was to explore the assumptions of the acculturation gap theory among the HCHS/SOL Youth population. Specifically, this study evaluates whether:

1. Familial cultural orientation gaps are associated with family functioning;

2. Familial cultural orientation gaps are associated with youth substance use susceptibility; and

3. Family functioning mediates the relationship between familial cultural orientation gaps and youth substance use susceptibility.

To comprehensively test these assumptions, the study used all three methods of conceptualizing and measuring cultural orientation gaps. Given the lack of studies comparing these methods in this population we did not have hypotheses as to which methods would yield associations.

METHODS

The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a population-based cohort study of 16,415 adults, 18–74 years old at baseline, who self-identified as Hispanic/Latino [27,28]. The HCHS/SOL Youth ancillary study is a cross-sectional study done between 2012 and 2014 among 1,466 youth ages 8 to 16 years living with a HCHS/SOL participant and free from known serious health issues [29]. The study sought equal proportions of male and female youth. All HCHS/SOL Youth participants resided with a HCHS/SOL participant, but the parent/caregiver participant in the HCHS/SOL Youth study was not required to be the HCHS/SOL participant nor a biological relative. All eligible youth in a family were invited, so multiple children residing with a HCHS/SOL participant could participate in HCHS/SOL Youth. Further details of the cohort and the sampling methods of HCHS/SOL Youth have been previously published [29]. HCHS/SOL Youth was reviewed and approved by institutional review boards at the five participating universities and the data can be requested from the HCHS/SOL administration.

MEASURES

Cultural Orientation

Children and caregivers participating in HCHS/SOL Youth each completed the Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA II) [30]. The ARSMA II consists of 12 items addressing English and Spanish language use as well as associations with non-Hispanic/Latino individuals, yielding two independent subscales measuring Anglo orientation and Hispanic/Latino orientation (both ranging 1-5). A high Anglo orientation score indicates a higher level of acculturation, and a higher Hispanic/Latino orientation score indicates a higher level of enculturation. Following recommendations for HCHS/SOL Youth analyses, the revised Anglo orientation scale for child participants was calculated by dropping two items relating to associations with non-Hispanics/Latinos (Cronbach’s α= 0.77), but the original Hispanic/Latino orientation scale was used (Cronbach’s α= 0.84) (31). For caregivers, both original scales were used (Anglo Cronbach’s α= 0.88; Latino Cronbach’s α= 0.82) [31].

Family Functioning

Youth reported family functioning using the 12-item General Functioning subscale of the McMaster Family Assessment Device [32]. The General Functioning subscale is scored as an average of the 12 items, with a higher score indicating worse family functioning (33). Family functioning scores were dichotomized in accordance with previous studies identifying a score of at least two as an indicator of poor family functioning [33]. The overall Cronbach’s alpha reliability was 0.77.

Substance Use Susceptibility

Overall youth substance use susceptibility was determined by combining previously validated algorithms to determine youth alcohol susceptibility and youth tobacco use susceptibility [7]. Youth who reported consuming alcohol or reported smoking in the past 30 days or reported that they might try alcohol or a cigarette within the next year or if a friend offered it to them were classified as susceptible to substance use. Those who reported ever using alcohol or smoking but did not indicate use within the past month or an intent to try again were classified as not susceptible to substance use.

Covariates

Previous literature suggests that age, gender, and ethnic identity for both responding caregivers and adolescents [16-19,22,25] as well as children’s immigrant generation [25,26] and Hispanic/Latino background [18] impact family functioning, adolescent substance use, and cultural gaps within caregiver-youth dyads. In addition, family socioeconomic status could impact the relationships between cultural orientation gaps and family functioning or youth substance use [19,22,25]. The child or the caregiver self-reported all covariates during their HCHS/SOL Youth clinic visit.

To measure individual ethnic centrality and ethnic regard, youth and caregivers individually completed an 8-item scale composed of the affirmation and belonging subscale from the Multigroup Ethnic Identity Measure-Revised (MEIM-R) and the measures on ethnic centrality and regard from the Multidimensional Model of Racial Identity scale [17,31,34]. HCHS/SOL Youth uses the average of all eight items to calculate total ethnic identity scores for both caregivers and children where a higher score indicates a stronger sense of ethnic identity. Hispanic/Latino background was grouped as Mexican; Dominican or Cuban; Central or South American; and Puerto Rican or mixed/other Hispanic/Latino background. HCHS/SOL Youth derives immigrant generations for child participants based on place of birth information reported by children and caregivers. The study defines first-generation children as a foreign-born child with foreign-born parents; second generation children as U.S.-born with at least one foreign-born parent; and third generation children as U.S.-born children with two U.S.-born parents. Foreign-born individuals are defined as those born in a foreign-country or U.S. territory. Family socioeconomic status was measured using the caregiver’s reported highest level of education categorized as less than high school, high school or equivalent, and more than high school.

ANALYSIS

From the total sample of 1,466, the study population was limited to study participants with non-missing explanatory, dependent, or covariate values (N=1,307; 89%). All statistical tests were two-sided and significant at α=0.05. All analysis utilized SAS software version 9.4 [35]. All analysis was generated using survey procedures to account for sampling weights and clustering due to survey sampling and family units [36].

Demographic differences in mean ARSMA II composite and subscale scores for HCHS/SOL Youth participants were examined using t-tests. P-values for mean differences between more than two categories were adjusted for multiple comparisons with the Tukey-Kramer test. Squared Pearson correlation coefficients for ARSMA II subscale scores among caregiver-youth dyads and children’s ethnic identity score were calculated using unadjusted linear regression.

Cultural gaps between caregiver-youth dyads were conceptualized using interaction, matched/mismatched, and difference methods. The impact of cultural identity was measured using multivariable logistic regression controlling for all covariates mentioned previously. Both caregivers’ and children’s ARSMA II subscales were kept independent to measure gaps in acculturation and enculturation. To test for mediation by family functioning, models testing the association between cultural gaps and substance use susceptibility were run with and without the mediator of child perceived family functioning and were compared to examine any appreciable differences in model estimates. For the interaction method, each ARSMA II subscale was standardized at the corresponding population mean. An interaction term of child and caregiver cultural orientation scores was entered in each regression model simultaneously with the main effects of their individual cultural orientation scores [14,25]. For the matched/mismatched method, ARSMA II subscale scores were dichotomized; a score above the midpoint of 2.5 was considered a high cultural orientation score. Then, family units were grouped based on whether their cultural orientations matched for each cultural domain. Lastly, for the difference method, the absolute differences in ARSMA II subscale scores were calculated within each dyad.

RESULTS

Mean Anglo orientation scores differed significantly by child’s sex, age, immigrant generation, Hispanic/Latino background, and perceived family functioning (Table 1). As expected, Anglo orientation scores increased with immigrant generation (F(980)=25.35, P=<0.001). Similarly, average Anglo orientation scores tended to increase with age (F(1,001)=3.06, P=0.05). Mean Hispanic/Latino orientation scores differed significantly by child’s age, immigrant generation, and Hispanic/Latino background. Hispanic/Latino orientation scores decreased with immigrant generation (F(982)=55.13, P=<0.001). Hispanic/Latino orientation scores for children aged 13-14 and those 15-16 were the same, but those aged 8-12 had the lowest scores. After adjusting for multiple comparisons, children of Puerto Rican background and from mixed or other Hispanic/Latino backgrounds had significantly higher Anglo orientation scores and lower Hispanic/Latino orientation scores than all other Hispanic/Latino groups.

Table 1.

Average Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA II) scores of youth in the HCHS/SOL Youth cohort by characteristics

Characteristic	No.	Anglo Orientation Score1	Hispanic/Latino Orientation Score2
		Mean (SD)	Mean (SD)
Total	1307	4.41 (0.03)	3.11 (0.04)
Sex
Male	667	4.49 (0.03)**	3.17 (0.05)
Female	640	4.33 (0.04)**	3.05 (0.05)
Age, years
8-12	718	4.35 (0.04)*	3.02 (0.05)*
13-14	348	4.42 (0.04)*	3.20 (0.07)*
15-16	241	4.51 (0.05)*	3.20 (0.08)*
Immigrant generation
First	290	4.17 (0.06)**	3.49 (0.07)**
Second	836	4.42 (0.03)**	3.16 (0.04)**
Third	181	4.70 (0.04)**	2.33 (0.09)**
Hispanic/Latino Group
Mexican	622	4.27 (0.04)**	3.35 (0.05)**
Dominican/Cuban	256	4.46 (0.05)**	3.00 (0.08)**
Central American/South American	172	4.44 (0.07)**	3.07 (0.08)**
Puerto Rican/Mixed/Other	257	4.68 (0.04)**	2.65 (0.09)**
Caregiver's highest level of education
Less than High School	511	4.41 (0.04)	3.17 (0.06)
High School/Equivalent	366	4.34 (0.06)	3.06 (0.07)
More than High School	430	4.46 (0.04)	3.07 (0.07)
Family functioning score4
≥ 2.00	656	4.34 (0.04)*	3.05 (0.05)
< 2.00	651	4.46 (0.04)*	3.16 (0.06)
Substance Use Susceptibility5
Yes	273	4.47 (0.06)	3.12 (0.07)
No	1034	4.39 (0.03)	3.10 (0.04)

¹ARSMA II American orientation score, ranging 1-5

²ARSMA II Hispanic/Latino orientation score, ranging 1-5

⁴A score of ≥ 2.00 on the McMaster Family Assessment Device General Functioning subscale is an indicator of poor family functioning.

⁵Substance use susceptibility was defined as self-reported consumption of alcohol or smoking in the past 30 days or openness to trying alcohol or a cigarette within the next year if offered by a friend.

^*P≤0.05

^**P≤0.001

Half (50%) of HCHS/SOL Youth participants reported General Family Functioning scores indicating poor family functioning. This group tended to have both lower average Anglo orientation scores and Hispanic/Latino orientation scores compared to youth with scores indicating healthy family functioning. About 21 percent of the youth indicated substance use susceptibility with 24/273 (9%) were susceptible to smoking only, 179/273 (66%) to drinking only, and 70/273 (27%) to both smoking and drinking. Those susceptible to substance use had slightly higher average Anglo and Hispanic/Latino orientation scores compared to those who did not indicate substance use susceptibility.

Generally, all correlations between cultural domains were moderate or weak (Table 2). The strongest correlation was between the two ARSMA II subscales for the caregivers (R²=0.33, P≤0.001). Youth’s Hispanic/Latino orientation scales were correlated with caregivers’ Hispanic/Latino orientation (R²=0.13, P ≤0.001) and Anglo orientation (R²=0.14, P≤0.001) scales. The ethnic identity scale for children was correlated with their Hispanic/Latino orientation scale (R²=0.06, P≤0.001), but was not correlated with either their caregiver’s Anglo orientation, Hispanic/Latino orientation, or ethnic identity scales.

Table 2.

Squared Pearson correlation coefficients between Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA II) and ethnic identity scales for caregiver-youth dyads

Variable		1	2	3	4	5	6
1	Youth Anglo orientation1	1.00
2	Youth Hispanic/Latino orientation2	0.09**	1.00
3	Youth’s ethnic identity3	0.00	0.06**	1.00
4	Caregiver Anglo orientation1	0.06**	0.14**	0.00	1.00
5	Caregiver Hispanic/Latino orientation2	0.04**	0.13**	0.00	0.33**	1.00
6	Caregiver’s ethnic identity3	0.01*	0.01*	0.00	0.01	0.5**	1.00

¹ARSMA II Anglo orientation score

²ARSMA II Hispanic/Latino orientation score

³Multidimensional Model of Racial Identity scale

^*P≤0.05

^**P≤0.001

Family Functioning

All methods of measuring cultural gaps indicated that there was no statistical evidence suggesting that differences between Hispanic/Latino orientations among caregiver-youth dyads significantly or meaningfully impact child reported family functioning (Table 3). The results slightly differed between methods when looking at Anglo orientation. The matched/mismatched and difference methods indicated differences in Anglo orientation within families did not impact family functioning. While the odds ratio for the interaction between the caregivers’ and children’s cultural orientations was similar to the other two methods, the interaction method also showed that the odds of children reporting poor family functioning significantly decreased as their Anglo orientations score increased independent of their caregiver’s cultural orientation (OR=0.74, 95% CI: 0.58-0.95).

Table 3.

Impact of cultural orientations by cultural domain within caregiver-youth dyads on poor family functioning and susceptibility of substance use using the interaction, match/mismatch, and difference methods

Cultural Domain	Poor family functioning1	Substance use susceptibility2	Substance use susceptibility, accounting for family functioning3
Hispanic/Latino Orientation4	OR (95% CI)	OR (95% CI)	OR (95% CI)
Interaction Method
Youth	0.96 (0.81, 1.13)	0.93 (0.73, 1.17)	0.93 (0.74, 1.18)
Caregiver	1.08 (0.88, 1.32)	1.18 (0.88, 1.58)	1.18 (0.87, 1.59)
Youth*Caregiver	0.95 (0.68, 1.32)	0.93 (0.59, 1.47)	0.95 (0.59, 1.51)
Match/Mismatch Method
Matched	REF	REF	REF
Mismatched	0.94 (0.80, 1.12)	0.95 (0.75, 1.20)	0.96 (0.75, 1.21)
Difference Method
Difference of 0.5	1.04 (0.95, 1.14)	1.11 (0.98, 1.25)	1.10 (0.98, 1.24)
Difference of 1	1.09 (0.91, 1.31)	1.23 (0.97, 1.55)	1.22 (0.96, 1.55)
Difference of 3	1.30 (0.76, 2.24)	1.85 (0.91, 3.76)	1.81 (0.88, 3.70)
Anglo Orientaiton5
Interaction Method
Youth	0.74 (0.58, 0.95)*	1.20 (0.90, 1.61)	1.25 (0.92, 1.68)
Caregiver	1.00 (0.83, 1.19)	1.03 (0.83, 1.27)	1.03 (0.83, 1.27)
Youth*Caregiver	0.76 (0.52, 1.12)	1.44 (0.90, 2.30)	1.48 (0.92, 2.38)
Match/Mismatch Method
Matched	REF	REF	REF
Mismatched	0.93 (0.78, 1.10)	1.17 (0.95, 1.43)	1.17 (0.95, 1.44)
Difference Method
Difference of 0.5	0.95 (0.87, 1.04)	1.00 (0.90, 1.10)	1.00 (0.91, 1.11)
Difference of 1	0.90 (0.76, 1.07)	0.99 (0.82, 1.21)	1.01 (0.83, 1.23)
Difference of 3	0.74 (0.44, 1.24)	0.98 (0.54, 1.77)	1.02 (0.56, 1.85)

All models controlled for child’s age, gender, immigrant generation, Hispanic/Latino group, and ethnic identity as well as caregiver's highest level of education and ethnic identity

¹Multivariable logistic regression of family functioning regressed by ARSMA II subscale scores within caregiver-youth dyads, controlling for covariates.

²Multivariable logistic regression of substance use susceptibility regressed by ARSMA II subscale scores within caregiver-youth dyads, controlling for covariates without family functioning.

³Multivariable logistic regression of substance use susceptibility regressed by ARSMA II subscale scores within caregiver-youth dyads, controlling for covariates with family functioning.

⁴ARSMA II Anglo orientation score

⁵ARSMA II Hispanic/Latino orientation score

Substance Use Susceptibility

Hispanic/Latino and Anglo orientation gaps between caregiver-youth dyads did not significantly predict child substance use susceptibility, but the trends indicated by the results slightly differed depending on the method of conceptualizing cultural orientation gaps (Table 3). Using the difference method it appears that Hispanic orientation gaps increased the odds of substance use susceptibility and the gaps in Anglo orientation have almost no effect. Anglo orientation discrepancies appeared to have more of an impact on a child indicating substance use susceptibility when using interaction and matched/mismatched methods with the odds of children indicating substance use susceptibility being higher for family units with mismatched Anglo orientation scores (OR=1.17, 95% CI: 0.95-1.44) and as gaps in Anglo orientations scores increased (OR=1.48, 95% CI: 0.92-2.38). Using all three methods, the models including family functioning produced nearly identical results to the models that did not include family functioning as a potential mediator.

DISCUSSION

This study examined the impact of cultural gaps on family functioning and youth substance use susceptibility as well as the acculturation gap theory assumption that family functioning mediates the relationship between cultural orientation gaps and childhood substance use susceptibility. All three methods provided complementary results when looking at the relationship between cultural orientations and child reported family functioning, but the interaction method suggested that children’s Anglo orientation is associated with perceived family functioning, independent of their caregiver’s Anglo orientation. While all results indicated that Hispanic/Latino and Anglo orientation gaps did not significantly predict child substance use susceptibility mediated by family functioning, the underlying trends of the results differed based on the method used to conceptualize cultural gaps with the interaction and matched/mismatched methods providing similar results that were opposite to the difference methods. There was no evidence of mediation on substance use susceptibility by perceived family functioning for either cultural domains using each method.

The incongruency between the results in this analysis and previous studies in support of the acculturation gap theory could be because the influence of discrimination or alienation was not accounted for which could impact both perceived family dynamics or substance use [15,21,37]. Also, these findings could be modified by Hispanic/Latino background or immigrant generation, which was not considered in this analysis [11,18,25,37]. Some researchers have argued that this theory may be over-stated in the case of Hispanic/Latino American families with U.S.-born children which were included in this analysis [22].

Strengths and Weaknesses

Due to the size of the HCHS/SOL Youth cohort, this is one of the larger analysis of the health or behavioral effects of cultural orientation gaps between caregiver-youth dyads among Hispanic/Latino youth. Still, this analysis is limited because it relied on cross-sectional data, making it difficult to establish a causal relationship between cultural orientation discrepancies and family functioning or substance use susceptibility, especially because individual cultural orientations as well as cultural gaps within family units are likely to change over time [20,37].

Additional limitations are present in this analysis due to the methods used to measure cultural orientations and the two outcomes of interest. While a bi-dimensional scale was used to measure cultural orientations, the ARSMA II scale used in HCHS/SOL Youth does not account for all domains of the acculturation process because it primarily measures language acculturation [38]. HCHS/SOL Youth did not ask participants about alternative tobacco product use which is currently on the rise in the U.S. among adolescents [1,5]. Finally, this analysis used alcohol susceptibility as the youth alcohol measure. In regards to measuring actual alcohol usage among youth, this measure may not be as reliable; however, this measure was used so the analysis could be compared and compliment previous HCHS/SOL Youth analysis on correlates of mental health and substance use [7].

NEW CONTRIBUTIONS TO THE LITERATURE

There is still much to learn about the impact of cultural orientations and cultural orientation gaps within family units on health behaviors and perceived family functioning. These relationships are very complex and should be examined in greater depth. Specifically, this analysis can be improved by incorporating aspects from the other domains of acculturative process as well as discrimination. Future research should particularly focus on how these relationships look over time, within different social contexts, and among varying Hispanic/Latino backgrounds. Understanding the effects of cultural orientations within family units directly impacts how professionals such as teachers, social workers, or psychologists interact with youth and their families [21]. Current popular thinking attributes acculturation gaps to many youth problem behaviors [21-25,37], but this might not always be the case. The results from this analysis underscores the need to refine the framework behind this theory and how cultural gap are measured.