Acculturation & Segmented Assimilation

Because Latinos comprise more than half of the Welcome Back participants, this section focuses on that population. However, there are several overarching acculturation factors that affect all Internationally Trained Health Professionals. Some of these factors are: gender; cross-cultural communication; and socio-economic issues.

Latinos

Acculturation
In the past two decades, researchers hypothesized that the longer Latinos remained in the United States, the more likely they would become integrated into the U.S. mainstream society, and thus their health outcomes would be better, relative to those recently arrived or with less time residing in the U.S. This hypothesis was eventually conceptualized into a theory of acculturation.

What is the role of acculturation in terms of Latinos' health?
In the United States, many studies have employed acculturation theory to examine the relationships between acculturation and health among immigrant populations. With respect to Latino populations, a wide range of risks and health outcomes have been studied, from depression, breast and cervical cancer, childhood immunization, health insurance, low birth weight, family planning and risky behaviors such as sexual behavior, alcohol use, AIDS risk, tobacco use and cigarette smoking.

The great majority of these studies found that there is a "healthy immigrant" trend. That is, Latino immigrants have many excellent health outcomes and indicators, such as higher immunization rates, less depression, and suicidal ideation, less smoking, less drug use, low rates of low birth weight, and higher social capital (Flores et al, 2002). These positive attributes tend to deteriorate with increased acculturation and successive generations (Flores, et al, 2002). Therefore, researchers have concluded that acculturation and subsequent generational residence in the U.S. is bad for the health of Latinos.

Although these studies provide important information to enhance our understanding of Latino behaviors and their relationship to health outcomes, there remains a serious limitation. The way in which acculturation instruments measure integration into the U.S. society are simplistic, individualistic measures that do not account for contextual level factors that may affect Latino's health, including for example immigration and immigrant, as well as other health and social policies.

From acculturation to segmented assimilation
In recent years, the discourse on the definition and operationalization of acculturation has been criticized. For example, Hunt (1999), and Gutman (1999) argue that the use of acculturation in health research is poorly understood; most research studies in this area have implicit, unstated assumptions that the associations between acculturation and health are linear, that acculturation is often judged from the view point of modern versus traditional values.

In fact, some researchers have called for complex models that enable our understanding of the role of acculturation, or assimilation in Latino health outcomes (Arcia E. Skinner M. Bailey D. Correa V. 2001). More recently, others have begun to explore these relationships, while incorporating a more complex conceptual approach, called segmented assimilation (Portes, A., & Rumbaut 2001); (Hirschman C. 2001) and (Harris, 1999), which suggests that people choose to adapt certain societal norms, but not others. Additionally, segmented assimilation calls for measuring Latino Health in multiple dimensions, at the individual, family, neighborhood and state and policy levels.

In California, most of the Latino population are immigrants. However, the children of these immigrants are likely to be U.S. born citizens. Therefore, the issue of assimilation will be an important factor that may be implicated in future health outcomes of the first, second and third generation Californian Latinos. Thus, California health and social service providers have both a challenge and an opportunity to implement innovative programs. The successes of these programs may contribute to the learning about Latino health outcomes in the U.S. Future evaluations in this community should employ complex models that incorporate migratory experiences and temporal dimensions of exposure to the U.S. mainstream culture, economic and political systems. Needless to say, California will need to engage in a plan that systematically and carefully documents the data that are needed to perform these types of analyses.

Assimilation and Latino Health: places and policies
The interrelationships between assimilation and health occur over time, within a particular context and a historical period. Understanding and explaining the differences in health outcomes between foreign born and U.S. born Latinos requires examination of places, migration patterns and policies.

Places and health
California as a geographic region where Latinos live, work, and play is a place bound by local, state and national policies that may impact its population. From a global perspective, the experiences of foreign-born Latinos must be looked at in their native context; that is, their countries of origin. At the same time, their present experiences in the United States may be shaped by the contexts of the states, the counties and residential areas. The experiences of Latinos in a place, may account for the differential distribution of disease, health, and well-being between immigrants and more assimilated Latinos. That is, place may play a role that has a protective, harmful or neutral effect on health outcomes of this diverse population. Linked to the place is also the timing of the exposure, whether it is during adulthood (immigrants) or throughout the life course (second and third generation).

Policies: mechanisms shaping place (s) and health
In the past decade, California engaged in and passed a wave of policies that in part, attempted to restrict the distribution of resources to immigrants and ethnic/minority populations. The passage of proposition 187, aimed at denying public education, basic social, and medical services to immigrant children and parents; the passage of proposition 209 to ban affirmative action practices in the state, and lastly proposition 227 to eliminate bilingual education in all public schools were approved by voters in a matter of 6 years, from 1994 to 2000. Although proposition 187 was eventually struck down by the courts as unconstitutional, propositions 227 and 209 are being implemented in the majority of the state. The passage of these policies sent a message to the entire country, and specifically to Washington, that something must be done to discourage the flow of immigrants, both legal and illegal into the state, and the nation.

Indeed, in 1996, Congress responded with the welfare reform act, a national policy referred to as PRWORA. Though a national law, one of its core purposes was to explicitly establish overlapping jurisdictions between states and the federal governments, passing the responsibility and power to the states to make independent decisions on certain provisions and its implementation as deemed necessary.

This policy dramatically changed the landscape of immigrant lives. While the major goals of PRWORA were to restrict eligibility for and access to public benefits for the U.S. population, and specifically immigrants, the effects of this law reached over and above its goals. Evidence from recent studies has shown that PRWORA has had "chilling effects," discouraging immigrants from accessing health, nutrition and other types of benefits for which they are in fact qualified (Fix, M, & Passel, JS. 1998). Even in California, a surprisingly -given the politics- but more generous state regarding public benefits, children of immigrants are having greater difficulties meeting basic survival needs compared to children of native-born parents. Compared to 30% of the children of natives, 38% of children of immigrants report having food security and affordability problems; 37% children of immigrants are living in crowded housing conditions, compared to only 12% of children of natives; 19% report having difficulties paying for rent and electricity bills, compared to 17%; finally, 15% pay at least half of their income for rent or mortgage, compared to 11% of the children from native born parents.

In addition, other legislative bills that allocate funds for children's health are important to consider in the context of Latino health. For example, the Child Health Disability and Prevention program (CHDP). This is one of the latest policy issues that particularly would have affected health of Latino children and other immigrant children in the state. The CHDP has been on the verge of elimination since 2001 by Governor Davis. Many children groups such as the American Academy of Pediatricians and Children Now have been concerned that eliminating this program would seriously limit preventive care and follow-up treatment for the over one million children who are eligible for Medical or healthy families but remain un-enrolled (CHDP Fact Sheet by the 100% Campaign). The second major concern is that school readiness and entrance for children is jeopardized if these funds were not made available. This year, the governor rescinded his proposal to shift 69 million from the CHDP program to the Medicaid and Healthy families. CHDP has been considered a safety net for many poor children who are ineligibile for government insurance. Judging from the history of this program in the political arena, at best, CHDP may remain a vulnerable bill that becomes attractive when budget cuts are necessary.

Although these policies did not aim to reconfigure the way in which services were provided to these populations, in some instances such as the case of eligible children not acquiring health insurance, providers were placed in the position to establish systems and mechanisms to enroll these children. Even with these mechanisms in place, over one million children in the state remain unenrolled. And it is difficult to sort out many the reasons, some of which may be related to the larger immigration policies at the state and national level, and the fear and anti immigrant sentiments they created.