Academic journal article Journal of Cultural Diversity

Acculturation as a Predictor of Health Promoting and Lifestyle Practices of Arab Americans: A Descriptive Study

Academic journal article Journal of Cultural Diversity

Acculturation as a Predictor of Health Promoting and Lifestyle Practices of Arab Americans: A Descriptive Study

Article excerpt

Abstract: A cross-sectional descriptive study was done using the Acculturation Rating scale of Arab Americans-ll, and the Health Promotion and Lifestyle Profile H to assess the relationship between acculturation and health promotion practices among Arab Americans. Findings showed that attraction to American culture was the most important predictor of physical activity; whereas attraction to Arabic culture was the most important predictor of stress management and nutritional practices. Results suggest that, when demographics are controlled, acculturation predicts various health promotion practices in different patterns among members of this group. These findings contribute to a better understanding of acculturation's influence on immigrants' health promotion practices.

Key Words: Acculturation, Health-promotion practices, Arab Americans, HPLP 11.


Acculturation is described as the dual process of cultural and psychological change that takes place as a result of contact between two or more cultural groups and their individual members (Berry, 2003). The process of acculturation is unique to each immigrant group (Berry) and is influenced by variables that are dependent on the cultural and sociopolitical characteristics of not only the ethnic group but also those of the dominant group (Berry).

Recent models of acculturation acknowledge that immigrants use different strategies to acculturate. Berry (2003) identifies four strategies in which acculturation occurs: The first is assimilation, which refers to complete acquisition of the dominant culture and lack of immigrants' interest in maintaining their own culture. The second is integration, whicn refers to embracing, valuing and integrating both the dominant and ethnic culture. The third is separation, which refers to the maintenance of immigrants' ethnic culture and rejecting or avoiding contact with the dominant culture. The fourth strategy is marginalization, which refers to the disconnection or exclusion of immigrants, whether voluntary or not, from their ethnic as well as the dominant culture (Berry, 2003).

Acculturation influences immigrants' health and health practices (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005). More specifically, health promotion practices have been connected to immigrants' level of acculturation and demographic characteristics (Hulme et al., 2003). Health promotion refers to an approach that is focused on health rather than on illness and recognizes the multidimensional nature of health. Health promotion and lifestyle practices are directed toward sustaining or increasing individuals' level of well-being, self-actualization, and personal fulfillment (Walker, Sechrist, & Pender, 1987). Studies have shown that health promotion practices are closely connected to prevention of chronic diseases and improved well-being (Center for Disease Control and Prevention [CDC], 2010).

Numerous studies have focused on investigating immigrants' health promotion-related behaviors such as exercise and physical activity, cancer screening, and dietary habits (Abraido-Lanza, Chao, & Florez, 2005; Acevedo, 2000; Marks, Garcia, & Solis, 1990). Although not consistent, most literature looking at the relationship between acculturation and health promotion practices reveals an overall positive influence of higher levels of acculturation on cancer screening (Crespo, Smit, CarterPorkas, & Andersen, 2001 ) and exercise practices (Marks et al., 1990) and a negative influence on smoking, alcohol use, dietary habits, and disease prevention practices (Edelman, Christian, & Mosca, 2009; Gordon-Larsen, Harris, Ward, & Popkin, 2003; Wilkinson et al., 2005 ). California (CA) is one of the most diverse states in the United States. An estimated 26.9% of its population is foreign born (U.S. Census Bureau, 2009); CA is home to the largest number of Arab Americans, estimated at one million (Arab American Institute [AAI], n.d.). Arab immigrants' health and health practices are understudied despite increased recent interest and research on this immigrant group (Aboul-Enein, 2010). Most of the studies on Arab Americans' health practices have been focused on smoking behaviors (e.g. Al-Omari & Scheibmeir, 2009; Kulwicki & Rice, 2003). Fewer studies have investigated cancer screening practices and substance abuse (Arfken, Kubiak & Farrag, 2009; Shah, Ayash, Pharaon & Gany, 2008). A number of studies have shown a high prevalence of hypertension, diabetes, and a high rate of risk factors for heart disease (Hatahet, Khosla, & Fungwe, 2002; Jaber, Brown, Hammad, Zhu, et al., 2003). Additionally, researchers have consistently shown a high prevalence of cigarette and waterpipe smoking among Arab Americans (Knishkowy & Amitai, 2005); both of such life-style practices are often cited as risk factors for morbidity and mortality.

Although the relationship between acculturation and health practices has not been studied sufficiently among Arab Americans, the handful of studies that involved health and acculturation in this group suggest that they are at high risk for acculturative stress and poor healtn outcomes (Arfken et al., 2009; Hattar-Pollara & Meleis, 1995; Jaber, Brown, Hammad, Zhu, & Herman, 2003). The influence of acculturation on the health behaviors and practices of this immigrant group remains largely unexplored. Thus, the aims of this study were (1) to assess health promotion and lifestyle practices of Arab American immigrants, and (2) to explore the relation between their demographic variables, acculturation and health promotion practices.



This research was part of a larger cross-sectional correlational study that was approved by the Institutional Review Board of a university in southern California.


The study involved 297 adult Arab Americans living in the southern California who were recruited using the snow balling technique. Eligible participants were adults above the age of 18 years, who were fluent in either English or Arabic, who had immigrated to the U.S. from any of the Arab countries, or who were born in the U.S. to parents who were both of Arabic decent.


Participants responded to the questionnaires in either English or Arabic language based on their choice. Two of tne measures used in the study were translated by the researcher using the methodology described by Brislin (1986). All measures were pilot tested on 30 participants prior to using them in the study. The translation and validation processes were described elsewhere (Jadalla & Lee, 2012).

Demographic and health data. Demographic and health data were assessed using the Demographic and Health Data Survey (DHDS). This survey, which was compiled and translated by the researcher, solicited data about socioeconomic variables as well as variables related to smoking and alcohol use.

Health promotion and lifestyle practices. Health promotion practices were assessed using the Health Promotion Lifestyle Profile II (HPLP-II) which was developed by Walker et al. (1987). HPLP-II is a 52-item, 4-point Likert scale that measures health promotion and lifestyle behaviors on six domains measured by six subscales. These subscales include health responsibility (HR), physical activity (PA), nutrition (N), spiritual growth (SG), interpersonal relations (IPR), and stress management (SM). An overall score for the total HPLP II scale was obtained by calculating the mean of all 52 items; whereas, the individual subscale scores were obtained by calculating the means of the items representing each particular subscale. The scores for both the total HPLP II and its six subscales can range between 1 and 4; higher scores indicate better health promotion practices. The Cronbach's alpha for the total scale in this study was (.93) and the Cronbach's alphas for the subscales were as follows: HR (.85), PA (.84), N (.72), SG (.78), IPR (.79), SM (.72). The values of Cronbach's alpha coefficients of the overall scale as well as the six subscales in this study showed that the HPLP II had adequate reliability in this study.

Acculturation. Acculturation was measured by a modified version of the Acculturation Rating Scale for Mexican Americans II (ARSMA II). The original ARSMA II was developed by Cuéllar, Arnold, ana Maldonado (1995) and has been used widely to assess acculturation among several ethnic groups including Asians (Schaefer et al., 2009). ARSMA II has 30 items and assesses acculturation on the following dimensions: language use and preference, ethnic identity and classification, cultural heritage, and ethnic behavior and interaction. The Acculturation Rating Scale for Mexican Americans II (ARSMA II) was modified so that all ethnic references to Mexican Americans were replaced with ethnic reference to Arab Americans. The translated and modified version of the ARSMA II for Arab Americans is referred to as the Acculturation Rating Scale of Arab Americans-II (ARSAA-II). To assess acculturation using ARSAA II, a factor analysis was run using principal axis factoring and direct Oblimin rotation wmch yielded two interpretable factors that were labeled as Attraction to American Culture (AAmC) and Attraction to Arabic Culture (AArC). These two factors were used to represent the acculturative modes of participants in this study. The correlation between the two factors was negative and weak (r = -.33). Reliability of the tool was strong with Cronbach's alpha coefficient of .89 for AAmC and .85 for AArC.

Analytic Strategy

According to Nunnally and Bernstein (1994) a ratio of five subjects per variable is recommended. Thus, the estimated minimum sample size for this study was 250. The sample size for this study yielded 297 completed questionnaires. The rate of missing data was less than 5%, and replacement of missing data was done using the expectation maximization procedure described by Schafer and Graham (2002). Data analysis was done using SPSS(TM) version 17. Descriptive statistics were used to describe the sample and multiple regressions were used to examine the relationship between demographic variables, acculturation, and health promotion measures.


The findings of this study are organized to describe: (1) the sample characteristics; (2) the health promotion practices of participants based on HPLP II, and smoking and alcohol use; (3) the associations between the demoraphic variables and HPLP II; and (4) the relationship etween the health promotion practices and acculturation.

Characteristics of the Sample

There were slightly more females (56%, n=167) than males (44%, n=130) who participated in the study. The average age of all participants was 38.6 years (SD = 14.3), and more Muslims (67%) participated than Christians (32.3%). The average annual household income for all participants was $66,000 (median = $50,000, SD = $58,000). On average, a typical participant in this study had lived in the U. S. for 17 years (SD=20). Table 1 summarizes the demographic characteristics of the sample.

The Health Promotion and Lifestyle Practices of Participants

The health promotion behaviors were measured by the Health Promotion and Lifestyle Profile II (HPLP II). The overall HPLP II mean score was 2.63 (SD= .42). Given that the 52 items of the scale were scored on a Likert score ranging between 1 and 4 (average mean =2.5), the overall HPLP II score obtained in this study was considered above the average. The means of the six subscales of HPLP II ranged between 2.20 and 2.99 (lowest for Physical Activity and highest for Spiritual Growth). There were no significant differences in the means based on gender; however, those who chose to respond to the English version of the questionnaire had a higher mean score on both the Spiritual Growth and Interpersonal Relations subscales than those who chose to respond to the Arabic version of the questionnaire. Table 2 shows the mean scores of health promotion behaviors by gender and language.

Smoking and alcohol use were assessed using selfreport. The rate of smoking was 13% and that of alcohol use was 14%. Participants who smoked were, on average, five years older than those who did not (M= 43 years, SD= 11; M= 38 years, SD= 14, respectively). Significantly more males than females reported smoking (f = -3.734, p = .000). For alcohol use, no significant difference in the mean age were noticed between those who used alcohol (M=40, SD=14) and those who did not (M= 38, SD= 14). Neither smoking nor alcohol use were significantly associated with education or income. Smokers differed significantly from nonsmoker on the Physical Activity suoscale only; smokers had a significantly lower mean Physical Activity score (M=l .88, SD= .66) compared to non-smokers (M=2.24, SD= .63) t (294) = -3.245, p < .001. No significant differences were noticed in the means of the different subscales between those who used alcohol and those who did not.

The Associations between the Demographic Variables and HPLP II

The associations between the demographic variables and the different health promotion practices were varied and over-all were moderate in strength. Some of these associations reflect expected patterns. For example, age was positively and significantly correlated with ractices relevant to Health Responsibility (HR) and tress Management (SM), and negatively with Physical Activity (PA). Additionally, income was positively and significantly correlated with Nutritional practices. Table 3 snows the correlations between all tested demographic variables and the health promotion practices subscales.

The Relationship between Health Promotion Practices and Acculturation

Regression analyses were used to assess whether the acculturation indicators (AAmC, AArC) were significant Çredictors of health promotion and lifestyle practices. he demographic variables (including age, income, and education) were significantly correlated with acculturation and thus were controlled for by entering them first in all the regressions, followed by the two acculturation factors AArC and AAmC. Acculturation factors were entered second. A significant difference in the means of AAmC and AArC was observed in this sample between those who responded to the English version of the survey and those who responded to the Arabic version of the survey (f AAmC (294) = -14.578, p < .0001, and t AArC (294) = 7.29, p < .0001). This result is expected because language is often considered as a proxy measure of acculturation and has often been used as a measure of acculturation; therefore in this study language as a variable was excluded from all analyses to prevent redundant measurements of acculturation. The findings of the regression analyses which are summarized in Table 4, show that acculturation (both AAmC and AArC) predicted overall health promotion practices |(R2= .08, R\d = .07, F (5, 290) =5.3, p <.001], and that either AAmC or AArC predicted specific health Çromotion practices (i.e. assessed by certain subscales). he findings on the subscale level show further differentiation in the relationship between acculturation and specific health promotion practices. For example, Attraction to Arabic Culture (AArC) distinctively predicted better practices relevant to nutrition and was the only significant predictor of the Nutrition [R2 = .06, R2 , = .04, F (5, 290) = 3.68, p < .001] and Stress Management subscales [R2=.05, $¿.=.03, F (5, 290) = 2.78, p < .001], AArC was also a significant predictor of Health Responsibility in addition to age [R2= .08, R2 .=.07, F (5, 290) = 5.30, p < .001]. On the other hand, Attraction to American Culture (AAmC) was the only significant predictor of better practices relevant to Physical Activity or exercise [R2=.0b, R2^ = .04, F (5, 290) = 3.61, p < .01]. Furthermore, AAmC, in addition to age, were the only significant predictors of Interpersonal Relationships [R2 =.12, R21~~,.= .10, F (5, 290) = 7.825, p <.001]. Although the vana~ce explained by acculturation (both on the overall scale and subscale levels) was not large, the fact that acculturation was a significant predictor of health promotion practices when demographic variables were controlled is an important finding and points to the role that acculturation plays in modifying health related behaviors.

Smoking and alcohol use were dichotomized and two separate logistic regressions were conducted to explore whether acculturation predicts these practices when demographic variables are controlled. Overall, the results showed that Attraction to AArC and gender were significant predictors of the likelihood of smoking. More specifically, male gender increased the likelihood of smoking by seven fold (OR = 7.33), and being attracted to Arabic culture increased the likelihood of smoking by almost two fold (OR = 1.71). On the other hand, being more Americanized (i.e. attracted to American culture), non-Muslim and employed all increased the likelihood of consuming alcohol. More specifically, being attracted to the American culture increased the likelihood of consuming alcohol by two folds (OR = 2.55). More detailed findings on these variables were reported elsewhere (Jadalla & Lee, 2012).


Our findings show that acculturation plays a role in the health promotion practices among Arab Americans. Specifically, the findings revealed that being more ethnic (more attracted to Arabic culture) predicted better nutritional and stress management practices; while being more Americanized (attracted to tne Americans culture) predicted better physical activity and interpersonal relationships.

These findings suggest that being Americanized, by way of adopting some of the practices that are more emphasized in tne American culture (such as exercise), resulted in better practices in terms of physical activity. Whereas, being ethnic, by way of continuing some etnnic practices plays a protective role in specific nealth behaviors, in this case healthier nutritional practices and better stress management among participants in this study.

Tnis study contributes to the limited body of literature about health promotion behavior and acculturation of Arab Americans. The relationships between health promotion practices, demographic variables, and acculturation were explored using regression analyses in a fairly large sample. The results showed that acculturation predicted nealth promotion practices; however, the pattern of this relationship was not uniform. This suggests that the different domains of health promotion practices are affected differently by acculturation.

The findings of this study are congruent with findings of other immigrant groups. For example, Bond (2002) found that a higher level of acculturation among Spanish immigrants in the U.S was associated with better overall health promotion practices (total HPLP II), health responsibility, and stress management practices. Similarly, Dixon, Sundquist & Winkleby (2000) showed that a lower level of acculturation among Mexican Americans was associated with better nutritional habits, and Crespo et al. (2001) documented that a lower level of acculturation was actually associated with a higher level of physical inactivity among the same immigrant group.

Overall, the few studies on Arab Americans reveal that although members of this group show better uptake of positive nealth responsibility practices, such as obtaining educational material about cardiovascular health (Hammad, Kysia, Maleh, Ghafoor, & Rabah-Hammad, 1997), they tend to be less amenable to changing other risky practices such as smoking (A1-Omari & Scheibmeir, 2009). Because research about health promotion practices among Arab Americans is limited, more studies are needed to verify and determine whether the factors associated with the health promotion practices found in this study remain stable and to identify other relevant factors. Clearly, further research is needed not only to identify the practices on which acculturation patterns make an impact, but also to identify culturally-based interventions that could improve health promotion practices.

Despite its wide use in the nursing literature, there are no studies reported on the health promotion practices among Arab Americans using HPLP II. The findings in this study revealed that the reliability coefficients of the six subscales and the overall scale of HPLP II support using it among adult Arab Americans. The overall scale reliability was excellent (a=.93), and two of the subscales (Health Responsibility and Physical Activity) show good reliability (.84 and .82 respectively). However, four of the six subscales (Nutrition, Spiritual Growth, Interpersonal Relations, & Stress Management) have acceptable reliability (coefficients range .72 - .79). The last four reliability indices suggest that, findings relevant to these subscales should be interpreted cautiously in this study despite the excellent overall scale reliability. Researchers wno used this tool among Arabs in Jordan (Al-Ma'aitah, Haddad, & Umlauf, 1999) also raised similar concerns and questioned the cultural relevance of some of its items.

Comparing the findings of Arab Americans in this study with those of other Arab groups on which studies are available (namely, in Jordan) (see Table 5) shows that Arab Americans in tne U.S. reported significantly higher scores, thus better health promotion practices on four of the six subscales (HR, PA, SG, IPR, and overall HPLP II). However, they did not differ in the remaining two subscales (N, and SM).

Although further studies are needed to explain the observed differences between Arab Americans and their counterparts in Jordan, a potential explanation is that Arab Americans in the U. S. are immersed in the American culture which places more emphasis on health promotion and prevention practices. Furthermore, Arab Americans in the U. S. are more exposed to health messages about health promotion practices in the media than their counterparts who live in Jordan, which may also explain this difference. In general, it has been documented that availability of resources and increased exposure to public health education is associated with improved health promotion practices. A similar pattern of differences on the HPLP II subscales was observed in a study that involved a group of Jordanian and Canadian students. Haddad, Kane, Rajacich, Cameron, & Al-Ma'aitah (2004) suggested that limited educational programs in Jordan about personal health care could have resulted in these differences. The fact that the findings on the nutrition subscales did not differ in this sample from those observed in Jordan suggests that nutritional habits and stress management practices among Arab immigrants remain fairly stable despite acculturation. Only one study (Hassoun, 1995) showed a similar finding in relation to stability of nutritional practices among Arab Americans in Michigan. More research is needed to verify this finding furtner and to explore the patterns of nutritional acculturation among this immigrant group and to find whether these patterns affect measurable health outcomes that are dependent on healthy nutritional habits.

Two limitations should be addressed in this study; the use of cross-sectional design and convenience sample. Both of these limitations indicate that any conclusions or generalizations should be made with caution and that there is a need to consider the possible biases that may have been invited by the nature of the design or sampling in this study.

Despite its limitations, this study contributes to understanding Arab Americans' health practices in relation to their acculturation. The large sample size, the use of a health promotion-specific measure, and the use of a bidimensional measure of acculturation to examine the different relationships in this study contribute to a systematic assessment of health practices and acculturation in this immigrant group.



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[Author Affiliation]

Ahlam A. Jadalla, PhD, RN, Marianne Hattar, PhD, RN, FAAN and Christiane C. Schubert, PhD

[Author Affiliation]

Ahlam A. Jadalla, PhD, RN, corresponding author, is an Associate Professor in the School of Nursing, California State University Long Beach. Dr. Jadalla may be reached at: or at: 562-985-1536. Marianne Hattar, PhD, RN, FAAN, is Chair of the Nursing Department, California State University Northridge. Christiane C. Schubert, PhD, is an Assistant Professor in the School of Medicine, Loma Linda University, Loma Linda California.

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