Requisitos de integración

Acculturation refers to a culture change due to the contact of two distinct cultural groups (Berry, 1992). At the individual level, psychological changes can occur which include changes in values, attitudes and behaviours. This is referred to as behavioural shifts.

Acculturation stress may also appear through social and psychological problems during the acculturation process. Acculturation can be seen as unidimensional or bidimensional (Lara et al., 2005). The unidimensional model refers to an individual degree of acculturation into the new culture in a continuous fashion. The bidimensional model entails a combination of the old and new cultures to different degrees: assimilation (adopting the new culture), separation (keeping the original culture), integration (adopting both) and marginalisation (excluding both).

In the context of researching ethnic differences in health, acculturation is often considered as the process through which ethnic minorities tend to adopt the cultural traits and behaviours of the population of the receiving country. The acculturation hypothesis focuses predominantly on migrants and tends to use duration of residence as a proxy for exposure to the new culture of the country of residence. However, migrant generations are also often used to understand intergenerational processes of acculturation. The acculturation hypothesis posits that as length of stay increases in the receiving country, minorities will increasingly adopt the health behaviours and health risk profile of the native population. In this context, Abraido-Lanza et al. referred to the acculturation process as “the health behaviors and acculturation hypotheses” (Abraído-Lanza et al., 2005). Although ethnic minorities’ health status tends to decline with greater acculturation, this process can be associated with both positive and negative effects on health behaviours (Abraído-Lanza et al., 2005, Lara et al., 2005). Positive effects of acculturation include an increased level of physical activity (Abraído-Lanza et al., 2005), health education and promotion as well as an increased use of health care services (Lara et al., 2005). However, the acculturation process is often viewed in Western societies as detrimental for ethnic minorities. Indeed, if we assume an initial “healthy migrant effect” (see section 2.3.3) and healthy habits, it is hypothesised that, as they acculturate, ethnic minorities will tend to adopt unhealthy behaviours such as a bad diet, an increased prevalence of smoking and alcohol consumption.

The acculturation hypothesis is generally assessed in relation to duration of residence in the receiving country but also through looking at second and third generations as an extension of the potential disappearance of the cultural buffer. Although descendants of migrants might have inherited some of the norms and culture passed on by their ancestors, they are likely to be greatly acculturated to their country of residence. Hence, the effect of different levels of acculturation on health linked to different patterns of health behaviours can be studied using migrant generations.

The acculturation hypothesis has a temporal and spatial aspect. It focuses on individual health trajectories influenced over time by the fact of living in a particular space with people of a particular culture. This trajectory is usually explored for a particular minority ethnic group within the context of the receiving country. However, Jasso argues that the health trajectory of immigrants exposed to specific factors such as health behaviour, health environment and health care system in the receiving country matters in relation to the health trajectory of similar non-migrants in the sending countries to assess comparatively the process of acculturation (Jasso et al., 2004). However, most research explores the effect of acculturation through assessing whether the health behaviours and health status of the minorities converge towards that of the majority population in the receiving country.

Initial research by Ziegler et al. explored the effect of duration of residence in the “West”

and degree of Western origin, as a proxy for Western lifestyles, on the risk of breast cancer in Asian-American women (Chinese, Japanese and Filipino women living in the US) (Ziegler et al., 1993). They found an 80% higher risk of breast cancer incidence in Asian women who lived more than 7 years compared to those who lived less than 7 years in the West (US). They also compared the risk of breast cancer in second, third and fourth generations to that of Asian immigrants and found an overall 60% higher risk of breast cancer incidence in Asian women born in the West compared to those born in the East (Asia). They found a gradient in risk as the number of parents and grandparents being born in the West increased, with higher breast cancer incidence than Whites for those with grandparents born in the West. In conclusion, this study supports increased risks of breast cancer with greater acculturation in Asian women living in the US.

In Western societies, an expected pattern of health associated with the acculturation process is a convergence of the health risk in a particular ethnic group towards the health level of the native population. When the health risk in minorities is low to start with compared to the native population and for a particular health outcome (e.g. cancer or mortality), it is expected to converge toward the health risk of the native population as duration of residence increase and over generations (Harding, 2003, Harding, 2004, Harding et al., 1996, Ziegler et al., 1993).

However, some evidence points to higher risks in descendants compared to the native population. For example, when the risk for a particular health indicator is already high in a specific ethnic group compared to the native population, rather than observing a convergence toward the health level of the population, some of the literature points to a continued increased risk in subsequent generations (Harding and Balarajan, 2001b). This supports the idea that

greater acculturation in minorities living in Western societies leads to a decline in health status in both migrants and subsequent generations rather than a convergence.

A strand of the literature focuses on the effect of acculturation on mortality outcome.

The focus on mortality is used here to shed light on a few key points. Initial evidence related to mortality as an outcome in the UK setting used both duration of residence in England and Wales (Harding, 2003, Harding, 2004) and migrant generations (Harding and Balarajan, 2001b, Harding et al., 1996). For example, looking at deaths from 1971 to 2000, Harding found that mortality from all causes and more specifically from cardiovascular disease and cancer increased with duration of residence in South Asian migrants (Harding, 2003). In contrast, she found no effect of duration of residence on mortality in Caribbean migrants, apart in the specific age group 45-54 years and for circulatory mortality (primarily stroke) (Harding, 2004). This points to varied effect of duration of residence on mortality for different ethnic groups in the UK. Further research in a UK setting found a high mortality risk in Irish migrants compared to the rest of the population in England and Wales (Harding and Balarajan, 2001b). This higher mortality risk was even more pronounced in Irish of second and third generations and adjustment for socio-economic status attenuated this higher mortality risk in immigrants only. This supports a greater health disadvantage in descendants. The literature in the European context provides mixed results in relation to the mortality outcomes of descendants when immigrants experience a mortality advantage to start with. In the Netherlands, Stirbu et al. found indications of convergence of lower cancer mortality rates towards the rates of the native Dutch population in immigrants as duration of residence increased and in second generations (Stirbu et al., 2006).

For both first and second migrant generations, cancer mortality did not reach the level of the native Dutch population and remained lower. In Belgium, Vandenheede et al. found a mortality advantage in immigrants wearing off with length of stay and a mortality disadvantage in second generations disappearing when SES was controlled for, for both Western and non-Western second generations (Vandenheede et al., 2015). Similarly to the Belgium example, Wallace found immigrants to have a lower mortality in England and Wales while descendants had a higher mortality compared to the host population (Wallace, 2016). The mortality disadvantage observed in descendants disappeared when SES was accounted for. The mortality findings in descendants might reflect the higher deprivation level that subsequent generations are exposed to through their life course.

In summary, the convergence or decline in health with greater exposure to the country of residence seems to occur in both migrants and descendants. It can vary by ethnic group within a specific context. Evidence points to descendants having the greatest disadvantage which tends to disappear once SES is accounted for.

Finally, the direction of the effect of acculturation on health is likely to be shaped by the original level of risk when entering the country of residence for specific ethnic groups and for specific health outcomes comparatively to the native population. The rapidity of the acculturation process might also be ethnic-dependent. For example, Smith et al. showed that the level of obesity in non-White ethnic minorities, with the exception of the Black Caribbean group, converged towards the risk of the White majority in England with greater acculturation (Smith et al., 2012). Indian and Chinese second generations were more likely to be obese than respectively Indian and Chinese immigrants and to a greater extent than that in other minority ethnic groups (Smith et al., 2012).