This document discusses measures of acculturation and their relationship to health outcomes in Hispanic populations. It describes the acculturation scales developed by Hazuda et al. that measure language use, cultural traditions, and social integration across generations. It also describes a less comprehensive acculturation measure used in the HHANES survey that focused only on language and ethnic identity. The document notes that socioeconomic factors often better predict health behaviors than acculturation alone. When controlling for access to care, acculturation showed weaker associations with preventive health service use.

1. ACCULTURATION
Definition
Acculturation is a process in which members of one cultural group adopt the beliefs and
behaviors of another group. Although acculturation is usually in the direction of a minority
group adopting habits and language patterns of the dominant group, accult uration can be
reciprocal--that is, the dominant group also adopts patterns typical of the minority group.
Assimilation of one cultural group into another may be evidenced by changes in language
preference, adoption of common attitudes and values, members hip in common social groups
and institutions, and loss of separate political or ethnic identification.
Measurement
The most comprehensive measure of acculturation for use in health services and
epidemiological research in Mexican-American populations was developed by Hazuda et al.
(1988). Hazuda's scales are based on a theoretical model that views acculturation as a multi-
dimensional process involving language, cultural beliefs and values and "structural
assimilation,"--the integration of members of the minority group into the social structure of
the majority group. The following are the items included in Hazuda's a cculturation scales.
Items in the Final Acculturation
and Structural Assimilation Scales:
San Antonio Heart Study, San Antonio, Texas 1979-82 (1)
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Dimensions Measured, Scale Items, and Scale Score Ranges
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 Acculturation
I. Early childhood experience with English versus Spanish language
1. What was the first language you learned to speak?
2. What language was spoken in your home when you were a child?
Scale range: 2-6 points
II. Adult proficiency in English
1. In your opinion, how well do you understand spoken English?
2. In your opinion, how well do you speak English?
3. In your opinion, how well do you read English?
Scale range: 3-12 points
III. Adult pattern of English versus Spanish language usage
1. What language do you usually use with your spouse?
2. What language do you usually use with your children?
3. What language do you usually use with your parents?
4. What language do you usually use at family gatherings, such as Christmas or other
holidays?
5. What language do you usually use with most of your friends?
6. What language do you usually with most of your neighbors?
7. What language do you usually use with most of the people at work?
8. In what language are the TV programs you watch?

2. 9. In what language are the radio stations you watch?
10. In what language are the books and magazines you read?
Scale range: 10-50 points
IV. Value placed on preserving Mexican cultural origin
1. How important do you feel it is for your children to know something about the
history of Mexico?
2. How important do you feel it is for your children to follow Mexican customs and
ways of life?
3. How important do you feel it is for your children to celebrate Mexican holidays
such as Cinco de Mayo or El Diez y seis de Septiembre?
Scale range: 3-15 points
V. Attitude toward traditional family structure and sex-role organization
1. Knowing your family ancestry or lineage, that is, tracing your family tree, is an
important part of family life.
2. It is important to know your cousins, aunts, and uncles and to have a close
relationship with them.
3. A person should remember other family members who have passed away on the
anniversary of their death, All Soul's Day, or other special occasions.
4. Brothers have a responsibility to protect their sisters while they are growing up.
5. While they are growing up, sisters have an obligation to respect their brother's
authority.
6. If they could live anywhere they wanted to, married children should live close to
their parents so that they can help each other.
7. In the absence of the father, the most important decisions should be made by the
eldest son rather than the mother, if the son is old enough.
Scale range: 7-35 points
 Structural Assimilation
I. Childhood interaction with members of mainstream society
1. When you were growing up, were your neighbors mostly Mexican American,
mostly Anglo, or about equal numbers of each?
2. When you were growing up, were your schoolmates mostly Mexican American,
mostly Anglo, or about equal numbers of each?
3. When you were growing up, were your close, personal friends mostly Mexican
American, mostly Anglo, or about equal numbers of each?
Scale range: 3-9 points
II. Adult interaction with members of mainstream society
1. Throughout your adult life, have your neighbors been mostly Mexican American,
mostly Anglo, or about equal numbers of each?
2. Throughout your adult life, have your close, personal friends been mostly Mexican
American, mostly Anglo, or about equal numbers of each?
3. (Are the people with whom you work closely on the job/Are the people with whom
you work closely on your last job) mostly Mexican American, mostly Anglo, or about
equal numbers of each?
Scale range: 3-9 points
By contrast, the measure of acculturation used in the Hispanic Health and Nutrition
Examination Survey (HHANES), 1982-1984, consisted of the following items (Solis et al.,
1990):

3. 1. What language do you speak?
2. What language do you prefer?
3. What language do you read better?
4. What language do you write better?
5. What ethnic identification do you use?
6. What ethnic identification does/did your mother use?
7. What ethnic identification does/did you father use?
8. Where was the birthplace of yourself, your mother, your father?
The ethnic identification items were only useful in discriminating different levels of
acculturation among Mexican-Americans. Among Cubans and Puerto Ricans, there was not
enough variability in answers to items 5-8 to permit meaningful distinctions among
individuals within those groups.
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Acculturation and Health
Acculturation has been studied in relation to prevalence of chronic illnesses and utilization of
health services. Aspects of the lifestyle of particular cultural groups (e.g., dietary habits,
patterns of physical activity) may affect the development of s pecific diseases. Beliefs about
causes, treatment, and prevention of illnesses may affect the utilization of health services.
Because acculturation and socioeconomic status may be closely related in a particular
community, research studies must be carefu l to distinguish acculturation effects from those
that can be linked to income and education.
Strong support for the hypothesis that acculturation explains a significant portion of health
behavior among Hispanics is generally lacking. In most studies, acculturation is strongly
associated with socioeconomic variables, such as education and income. When adjustments
are made for socioeconomic status, the relationship between dimensions of acculturation and
health status or health behavior weakens or disappears altogether. For example, in an analysis
of the use of preventive services (physical, den tal, eye examinations, Pap smear and breast
exam) in the Hispanic HANES survey, Solis et al. (AJPH, 1990) found that utilization was
predicted more strongly by access to care than by acculturation, after controlling for age
education, and income. Althoug h language preference predicted utilization, the authors
concluded that the language barrier should be viewed as another access variable, and not as a
cultural factor.
Assignment:
Compare the items in the acculturation measure of Hazuda and the HHANES measure. What
dimensions of acculturation do they have in common? What dimensions are missing from the
HHANES measure? Do you believe the HHANES acculturation measur e is adequate for
large-scale health surveys in Hispanic subpopulations? Why or why not? Is Hazuda's
measure a good substitute? Why or why not?
References:

4. (1) Hazuda HP, Stern MP, Haffner SM: Acculturation and assimilation among Mexican
Americans: scales and population-based data. Soc Sc Q. 1988;69:687-706. Solis JM, Marks
G, Garcia M, Shelton D: Acculturation, access to care, and use of preventive services by
Hispanics: Findings from HHANES 1982-84. Am J Public Health 1990;80 (Suppl):11-19.
Hazuda HP, Haffner SM, Stern MP, Eifler, CW: Effects of acculturation and socioeconomic
status on obesity and diabetes in Mexican Americans. Amer J Epidemiology 1988;128:1289-
1301.
Suarez L: Pap smear and mammogram screening in Mexican-American women: The effects
of acculturation. Amer J Public Health 1994;84:742-746.
Marks G, Solis J, Richardson JL et al.: Health behavior of elderly Hispanic women: Does
cultural assimilation make a difference? Amer J Public Health 1987;77:1315-1391.
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