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Problematic alcohol use in Hispanic emerging adults: the role of perceived discrimination, cultural identity, and salient cultural values
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Problematic alcohol use in Hispanic emerging adults: the role of perceived discrimination, cultural identity, and salient cultural values
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Content
Problematic alcohol use in Hispanic emerging adults:
The role of perceived discrimination, cultural identity, and salient cultural values
A Dissertation Presented to the
Faculty of the Graduate School of the
University of Southern California
In Partial Fulfillment of the
Degree Requirements for the
Doctorate of Philosophy (PhD)
(Preventive Medicine / Health Behavior Research)
Keck School of Medicine
Department of Preventive Medicine
Institute for Health Promotion and Disease Prevention Research
Timothy J. Grigsby, B.A.
August 2016
1
Table of Contents
Acknowledgements ...................................................................................................................................... 2
List of Tables ................................................................................................................................................ 3
List of Figures .............................................................................................................................................. 4
Ch. 1: General Introduction ....................................................................................................................... 5
Background and Significance ................................................................................................................. 5
Literature Review .................................................................................................................................. 13
Theoretical framework ......................................................................................................................... 21
Study Aims ............................................................................................................................................. 24
Chapter 2: Study Methods ....................................................................................................................... 27
Participants and Procedure .................................................................................................................. 27
Attrition analysis ................................................................................................................................... 28
Measures ................................................................................................................................................ 29
Chapter 3: Changes in familism, respeto and fatalism during emerging adulthood and its
relationship with negative alcohol use consequences in Hispanic emerging adults: Differences by
gender ......................................................................................................................................................... 34
Background and Rationale ................................................................................................................... 34
Analysis Plan .......................................................................................................................................... 40
Results .................................................................................................................................................... 41
Discussion ............................................................................................................................................... 44
Chapter 4: Perceived discrimination predicts negative and positive alcohol use consequences, but
not alcohol use frequency, among Hispanic emerging adults ............................................................... 50
Background and Rationale ................................................................................................................... 50
Analysis Plan .......................................................................................................................................... 54
Results .................................................................................................................................................... 55
Discussion ............................................................................................................................................... 58
Chapter 5: Quantity of alcohol use problems modifies the effect of perceived discrimination on
physical intimate partner violence perpetration for Hispanic emerging adults .................................. 65
Background and rationale .................................................................................................................... 65
Analysis plan .......................................................................................................................................... 71
Results .................................................................................................................................................... 72
Discussion ............................................................................................................................................... 73
Chapter 6: General Discussion and Conclusion ..................................................................................... 77
What this work adds to the literature ................................................................................................. 77
What remains unknown? ...................................................................................................................... 79
Where do we go from here? ................................................................................................................. 81
Conclusion .............................................................................................................................................. 84
References
.............................................................................................................................................
102
2
ACKNOWLEDGEMENTS
I am indebted to the many people who have supported me on this adventure through
graduate school and for their dedication to helping me achieve more than a goal, but a dream I’ve
had for more than a decade. First, I must thank my beautiful and talented wife Isabel for always
being a bright spot in my life and for keeping me grounded in the tumultuous ride that is life.
You are my inspiration to be a better scientist, a better teacher and a better person—the world
needs more people like you. My children—Theo, Ariel and Aurora—thank you for putting a
smile on my face through some of my toughest tribulations and for motivating me to do more
with my life than I could have ever imagined. Also, a special thank you to my parents for
tolerating my quirks and reminding me that I can succeed no matter the odds.
Of course, I cannot express enough gratitude for my remarkable and talented faculty
mentor, Dr. Jennifer Unger. Your unwavering commitment to my success as a scholar, attention
to my needs as your student and appreciation for my contributions to the many projects I’ve had
to pleasure to work on with you will never be forgotten. My appreciation also goes to the other
members of my committee for their guidance and support: Dr. Steve Sussman and Dr. Adam
Leventhal. Dr. Sussman, in particular, it was a pleasure getting to know and work with you on so
many projects over the last few years. I will miss our intellectual conversations and the
intermittent moments of humor that always snuck in. I am also very lucky to have had the
support of Marny Barovich whose incredible skills have make our lives as students so much
smoother. Also, my gratitude goes to Daniel Soto who, despite his tireless work ethic spread
about multiple projects, always found the time to share his wisdom with me. Finally, I would
also like to acknowledge my terrific friend and colleague, Myriam Forster, for keeping me
dedicated, hard working, and passionate about the work we do.
3
LIST OF TABLES
Supplemental Table 1…………………………………………………….…………………..37
Supplemental Table 2……………………………………………………………….………..38
Study 1 – Table 1……………………………………………….……………………………..91
Study 1 – Table 2……………………………………………………………………………...92
Study 1 – Table 3……………………………………………………………………………...93
Study 1 – Table 4……………………………………………………………………………...94
Study 2 – Table 1……………………………………………………………………………...95
Study 2 – Table 2……………………………………………………………………………...96
Study 3 – Table 1……………………………………………………………………………...98
Study 3 – Table 2……………………………………………………………………………...99
Study 3 – Table 3………………………………………………………………………...…..100
4
LIST OF FIGURES
Theoretical model guiding dissertation studies………………………...……………………..87
Paths of theoretical model tested in study 1…………………………………………………..88
Paths of theoretical model tested in study 2 excluding covariates…………………………..89
Paths of theoretical model tested in study 3…………………………………………………..90
Study 2 – Figure 1: Lowess smoothing plots exploring the relationship between alcohol use
frequency with negative (a) and positive (b) alcohol use consequences…………….……….97
Study 3 – Figure 1: Visual representation of the relationship between perceived
discrimination at fixed estimates of alcohol use problems in EA wave 2 on the predicted
probability of physical IPV perpetration at EA wave 3 with 95% confidence intervals....101
5
CH. 1: GENERAL INTRODUCTION
Background and Significance
As of 2013, the Hispanic/Latino population comprised 17% (54 million) of the United
States (U.S.) population and recent estimates suggest this number will grow to 31% (128.8
million) by 2060 (Ortman, 2014) making Hispanics/Latinos the largest minority group in the
United States. National estimates suggest that during adolescence, between the ages of 12-17,
Hispanics have the second highest rate of past 30-day alcohol use (15.2%) following non-
Hispanic White peers (18.2%), but outpace other racial/ethnic minority groups (Chen, Yi &
Williams, 2009). In emerging adulthood, ages 18-25, Hispanics continue to show a higher rate of
alcohol use relative to other racial/ethnic minority groups with the exception of Native
Americans (Chen, Dufour & Yi, 2005). A similar pattern of findings for marijuana and illicit
drug use is evident as estimates suggest that 8.3% of Hispanics aged 12 or older use illicit drugs
and this estimate escalates considerably for full-time college students where the rate of illicit
drug use is 20.6% (SAMHSA, 2013).
Hispanic and African-American adults are more likely than non-Hispanic Whites to
report alcohol dependence symptoms or social consequences from alcohol use (Mulia et al.,
2009). During adolescence and emerging adulthood, however, Hispanics report a higher rate of
alcohol related consequences than African-American drinkers (Muthen & Muthen, 2000; Mulia,
Greenfield & Zemore, 2009). Likewise, the rates of substance abuse and dependence are slightly
higher for Hispanics relative to non-Hispanic Whites during this life stage (SAMHSA, 2013).
Hispanics and other ethnic minority groups are also disproportionately affected by certain
negative social consequences from illicit substance use compared to non-Hispanic Whites, such
as arrest for drug related offenses (Mitchell & Caudy, 2015). Whether this reflects an increased
risk for negative substance use consequences among minority groups or a propensity by
6
authority figures to disproportionately punish ethnic minorities, these prevalence rates
underscore the need to identify and address problematic substance use with ethnic minority
groups to improve individual well-being and reduce social harm.
The goal of the present line of inquiry is to identify cultural risk and protective factors for
alcohol related negative consequences among Hispanic emerging adults. Emerging adulthood is
used to describe the developmental changes that occur between the ages of 18-25 years (Arnett,
2000). In Western societies, this timeframe is typically described as a time of exploration and
identity formation. Studies have documented how role transitions during this timeframe may be
associated with increased rates of substance use (Arnett, 2005; Allem, Soto, Baezconde-
Garbanati, & Unger, 2013), and have suggested that the stress accompanying this transitional life
stage may put individuals at an increased risk for substance use. During this same time, alcohol
becomes legally available and becomes an integral part of social activities—especially among
college students (Lee et al., 2011).
Rationale for focusing on negative consequences of use
Negative alcohol use consequences are defined as the proximal and deleterious effects of
alcohol use. These consequences can impact multiple domains of functioning including, but not
limited to: intrapersonal problems (e.g., being unable to cut down on use), occupational
problems (e.g., missing school/work or neglecting responsibilities), physical health problems
(e.g., lack of self-care or infection from injection use), micro-social problems (e.g., getting into
arguments or physical altercations with friends or loved ones), and macro-social or legal
problems (e.g., driving under the influence or committing crime to purchase alcohol). Individuals
experiencing negative consequences as a result of their alcohol use have been described as
“problem users” (used here interchangeably with “alcohol related negative consequences”) to
7
catalog their continued involvement with alcohol while continuing to experience negative
consequences that result.
Despite limitations stemming from numerous methods to operationalize and measure
problem alcohol use (Grigsby, Forster, Unger & Sussman, 2016), examining negative
consequences of alcohol use is an important scientific endeavor for several reasons. First, alcohol
misuse is a public health problem as negative alcohol use consequences can impact individuals
other than the alcohol user. For example, nearly a third of all traffic-related deaths in the U.S.
involved an alcohol-impaired driver in 2013 and estimates suggest that the economic cost of
alcohol-impaired driving incidents is in the tens of billions of dollars (National Highway Traffic
Safety Administration, 2014). The rate of alcohol related emergency department visits has
declined slightly from 2004 to 2010 (239 to 215 per 100,000), but remains among the top reasons
for emergency department visits and the rate of visits for combined alcohol and drug use has
increased in the same time frame (DAWN, 2013). Second, a chronicity of negative alcohol use
consequences over several months is typically used as the principal criteria to diagnose an
alcohol use disorders and are integral in defining abuse, dependence or addiction (American
Psychiatric Association, 2000). Therefore, early identification and intervention of problem use
could interrupt escalation to alcohol use disorders.
Third, alcohol use consequences may be an advantageous measure of misuse, from a
methodological standpoint, as opposed to cataloging frequency or quantity of use. For example,
when examining alcohol use frequency a researcher must consider the size and alcohol
concentration of the drinks participants report consuming and take into consideration individual
physiological thresholds in the effect of alcohol on the brain and nervous system. Given the
variation within and between these constructs, and that they are largely ignored in survey
8
research, examining negative consequences may provide a more accurate measure of misuse. In
addition, it also improves the specificity of clinicians and researchers as to the psychological and
social impact of alcohol misuse. Furthermore, as described below, factors that predict quantity or
frequency of use do not always predict the experience of negative consequences suggesting that
frequency and quantity of use differs from problematic (i.e., consequential) use. Lastly, there is
evidence to suggest that the experience of negative alcohol use consequences differ by
race/ethnicity (Frank et al., 2008; Mulia, Ye, Greenfield, & Zamore, 2009; Williams, Costa, &
Leavell, 2010) while statistically significant differences in frequency or quantity of use appear
similar. This discrepancy may stem from risk and protective factors that reflect sociocultural
factors unique to racial/ethnic group membership and more work is needed to identify the
reasons for observed differences in problem alcohol use in order to strengthen intervention
strategies by integrating culturally appropriate content.
There is also evidence to suggest factors that predict frequency or quantity of alcohol
differ from those that predict negative alcohol use consequences. For instance, Lecci and
colleagues (2002) found that self-efficacy and (nonalcoholic) goals predicted alcohol use
consequences, but not alcohol use frequency. Another study found that self-regulation moderated
the relationship between parental alcoholism and experiencing alcohol related problems, but this
effect was not present when predicting alcohol use (Pearson, D’Lima, & Kelly, 2011). In
combination, these findings suggest that problem users—those continuing to engage in alcohol
use despite experiencing negative consequences—are a unique subgroup of occasional and
regular users. More importantly, perhaps, this evidence suggests that primary prevention
programs focusing on predictors of initiation or regular alcohol use may not be as effective in
identifying individuals on a trajectory towards problem alcohol use.
9
However, there are factors that predict both alcohol use frequency and the experience of
negative consequences including depression, personality traits and peer use (Gonzalez, Reynolds
& Skewes, 2011; Kenney, Lac, LaBrie, Hummer & Pham, 2013). In most cases, alcohol use
frequency is, logically, examined as a mediator. As one might expect, the likelihood of
experiencing negative alcohol use consequences escalates with higher self-reported frequency or
quantity of use (for review, see Grigsby et al., 2016; Mallett et al., 2013).
Cultural factors and negative alcohol use consequences
In addition to these universal predictors, risk and protective factors related to alcohol use
behavior that reflect cultural processes may be more relevant to understanding alcohol use and
related consequences in minority groups. Culture is defined loosely as a set of shared values,
beliefs, language, behaviors, and customs (Dana, 1998), and plays a significant role in identity
development and social interactions at the individual and community level. Culture is a broad
social construct, and drug use researchers have more commonly examined acculturation—the
process of leaving one’s culture of origin and adapting to the values, beliefs, customs and
language of a host culture (Schwartz, Unger, Zamboanga, & Szapocznik, 2010)—when
describing cultural influences on health behavior and mental health outcomes among minority
populations in the United States. The process of acculturation is multidimensional (Schwartz et
al., 2010) and embodies a multitude of factors in the individual, community and structural
domains. The present studies described here do not attempt to address the myriad complexities of
acculturation, but instead focuses on specific cultural stressors, traits, values, and cultural
identity as it relates to problematic alcohol use. This approach is advantageous as (a) the study
sample consists of mainly second and third generations of Hispanic emerging adults who are not
10
immigrating and adjusting to a new country and culture and (b) identifying specific cultural risk
and protective factors can be integrated into intervention programs for this population.
A growing body of work has examined the role of cultural factors with substance use in
ethnic minority populations, as discussed below, but there has been little work examining the
role of cultural factors with alcohol use consequences. As personalized feedback interventions
(PFIs) have become an increasingly popular strategy for harm reduction with high-risk alcohol
users experiencing negative consequences, especially in college settings (Miller et al., 2013),
overlooking relevant sociocultural factors may undermine their efficacy with minority
populations. A burgeoning body of evidence has begun to document important cultural processes
in problem use during emerging adulthood.
One study found that stronger orientation toward Hispanic or Anglo-American practices
was not related to problematic substance use (Grigsby, Forster, Soto, Baezconde-Garbanati, &
Unger, 2014), but it is unclear how well these constructs capture specific cultural processes.
Pederson and colleagues (2013) found that higher levels of acculturation and collective self-
esteem are protective against experiencing negative alcohol use consequences for a sample of
Asian-American young adults, but it is unclear whether this association is present for Hispanic
adults of the same age. The authors also found evidence that discrepancies between acculturation
level and dimensions of collective self-esteem tend to be related with higher levels of alcohol
related negative consequences. For example, participants with lower acculturation (having a
greater affiliation with the culture of their country of origin) and lower membership self-esteem
(feeling they were not a worthy member of their racial/ethnic group) tend to report more
consequences suggesting that marginalization (Berry, 2005), or feeling excluded by members of
11
the host and origin country, may be an important risk factor for engaging in problematic alcohol
or drug use.
These findings tend to focus on broad conceptualizations of cultural risk and protective
factors and may not be sensitive to important sociocultural processes relevant to immigrant and
non-immigrant Hispanics (described below in the literature review) that can enhance or decrease
the risk of using or misusing alcohol and drugs. Nonetheless, this growing body of evidence
suggests that incorporating sociocultural factors into existing intervention programs could
improve effectiveness. More work is needed to identify specific and modifiable sociocultural risk
and protective factors. Recently, Cheng and Mallinckrodt (2015) found evidence that
experiencing racial/ethnic discrimination was associated with problematic alcohol use in a
sample of Hispanic/Latino college students. Unfortunately, the statistical models did not control
for other relevant sociocultural processes or known predictors of alcohol related negative
consequences among college students.
Methodological limitations in the study of cultural risk and protective factors
A major criticism of cultural research has been the lack of integrating cultural risk and
protective factors into larger ecological models. It is imperative that we enhance our
understanding of whether sociocultural stressors (e.g., perceived discrimination) and cultural
traits and values (e.g., familism) explain unique portions of the variance in problematic alcohol
use (i.e., negative consequences) after controlling for known intrapersonal and contextual
factors. Examining cultural risk and protective factors using bivariate statistical models or only
in the presence of other cultural variables may undermine the dynamic relationship between
cultural factors and negative health behaviors. Such statistical models may result in under- or
overestimation of the predictive utility of any cultural factor independently or in combination
12
(i.e., interaction) in predicting behaviors such as problem alcohol use. Moreover, investigating
the role of cultural factors without considering other relevant psychological or contextual factors
my lead to biased estimates of their impact on negative health behaviors. As a result, prevention
programs may unnecessarily incorporate elements that have no substantive relationship with
problem behaviors after accounting for other theoretically meaningful risk and protective factors.
Issues surrounding the methodological limitations of research with different cultural factors are
elaborated below in the literature review.
The overarching goals of this research are to partially address these gaps in the literature
and improve our understanding of how cultural factors relate to problematic alcohol use among
Hispanic emerging adults. Specifically, these studies have been designed to describe whether,
and how, (i) salient cultural values and traits are related to negative alcohol use consequences
over time, (ii) the experience of cultural stress (i.e., perceived discrimination) relates to negative
and positive alcohol use consequences, (iii) whether a stronger sense of ethnic identity can buffer
the negative impact of cultural stressors on alcohol use and related consequences, and (iv) how
cultural stress and problem alcohol use contribute to other behavioral problems, specifically
intimate partner violence victimization and perpetration. These studies focus on the
interrelationships of salient cultural values (familism, respeto, fatalism), sociocultural stress (i.e.,
perceived discrimination) and ethnic identity to better understand alcohol use involvement in a
sample of Hispanic emerging adults using the Theory of Triadic Influence as a theoretical
framework. Figure 1 presents a graphical representation of the major cultural variables and their
relation to alcohol use and negative consequences investigated in this work.
13
Literature Review
Cultural values and traits are influenced considerably by the experience of living between
one’s culture of origin and a host (dominant) culture. During the process of acculturation and the
inherent social and personal stressors associated with it, individuals must struggle to balance the
needs of each culture (Portes & Rumbaut, 2001). Successful navigation of this process produces
biculturalism—competence or an ability to handle the needs of two, sometimes conflicting, sets
of values, beliefs and attitudes. Such individuals possess stronger anti-drug normative beliefs
(Kulis, Napoli & Marsiglia, 2002) and are less likely to initiate or escalate drug use throughout
adolescence and young adulthood (Shih, Miles, Tucker, Zhou, & D'Amico, 2012). Also, there is
evidence that maintaining cultural values from one’s origin country may increase risk of
discrimination in Hispanic adolescents and this may lead to increased smoking, for example
(Lorenzo-Blanco, Unger, Ritt-Olson, Soto, & Baezconde-Garbanati, 2013). To date, the majority
of the evidence regarding the influence of three salient cultural values (familism, respeto and
fatalism) commonly explored in association with substance use and problem use has relied on
cross-sectional data and has been limited to adolescent or college samples. However, these
cultural values can vary over time as individuals mature and gain more experience with external
stressors and resources for resilience. Moreover, individuals that retain the cultural values of
their origin culture into adulthood may incorporate these values into their concept of self-
identity, but this has not been explored empirically with Hispanic populations. The present
investigation hopes to partially fill this gap by exploring the dynamic relationship between these
three cultural factors and alcohol use consequences over time in a sample of Hispanic emerging
adults.
Salient cultural values and traits in Hispanic/Latino populations. Cultural values reflect
global norms regarding beliefs and behaviors of people who share a similar lineage or occupy the
14
same geographic space. Cultural values can shape an individual’s attitudes toward specific health
behaviors including substance use (Unger et al., 2006). Familism, resepto and fatalism have been
documented as core cultural traits in Hispanic populations (Cuellar, Arnold, & Gonzalez, 1995;
Antshel, 2002; Halgunseth, Ispa, & Rudy, 2006), and as described below, there has been
documented evidence that each has a specific relationship with experimentation and escalation of
alcohol and drug use.
Familism is a construct that differs from other measures of family cohesion as the former
implies a sense of duty and responsibility to the family unit while the latter indicates the extent to
which family members share emotional bonding (Marsiglia, Kulis, Parsai, Villar, & Garcia,
2009). Relative to Whites, Hispanics tend to be more family centered (Ramirez et al., 2004) and
are distinguished by higher levels of family unity, social support and interdependence among
family members (Gaines, Marelich & Bledsoe, 1997). Stronger relationships in the family
domain are believed to have a strong protective effect on substance use behavior (Marsiglia,
Parsai, & Kulis, 2009). This may be due to increases in parental communication and
involvement, factors that have been shown to be protective in multiethnic samples (Pilgrim,
Schulenberg, O’malley, Bachman, & Johnston, 2006; Tobler & Komro, 2010).
However, the adoption of host culture (i.e., American) values may weaken family bonds
and the influence of parents on adolescent behavior as evidenced by a finding by Gil et al. (2000)
documenting that acculturative stress was inversely associated with familism among Hispanic
adolescents. While findings appear to support the notion that familism, or facets of familism, are
protective against substance use and related problems (Dillon, La Rosa, Sastre, & Ibanez, 2013),
other studies have found that the protective effect of familism on substance use diminishes when
other relevant covariates (e.g., peer use) are accounted for (German, Gonzales, & Dumka, 2009;
15
Ramirez et al., 2004). This discrepancy in the literature suggests more work is needed to
understand the role of familism in a broader framework to explain substance use behavior and
problem use, especially in emerging adult samples where little work has been done in this area.
Respeto is a cultural value related to familism but defined more specifically as showing
respect for others based on age, gender and authority (Antshel, 2002), and typically emphasizes a
child’s duty to show respect for their parents (Garcia, 1996). Respeto may be an important factor
in alcohol use outcomes in cultures where family unity is a central component of the social
philosophy. The role of respeto as a risk or protective factor of substance use is debatable, and
may depend to some extent on the substance use values and behaviors of the parent (Unger et al.,
2006) although this has not been investigated empirically. This heightened respect for authority
figures, and parents specifically, may be more prominent for females than for males (Zayas,
Kaplan, Turner, Romano, & Gonzalez-Ramos, 2000), especially in cases where substance use
may be an indicator of defiance or reflect a differential impact of cultural stress across genders.
Work by Shih et al. (2012) did not find evidence that higher parental respect was protective for
alcohol initiation for Hispanic adolescents while Soto et al. (2011) suggest that it is protective
against lifetime alcohol use but not tobacco or marijuana use. Still, it remains unknown if this
conclusion extends to other substances or is generalizable to emerging adult populations.
Fatalism has been described as the belief, or personality trait, that future events are
controlled by external elements such as fate, chance or divine intervention (Cuellar et al., 1995).
The term has been likened to the external locus of control construct (Lefcourt, 2014) in that both
attribute success, disease or other meaningful life events to external influences. Moreover,
psychologists have suggested that fatalistic beliefs constitute a passive coping style that can
reduce an individual’s ability to address past and present stress or trauma (Pole, Best, Metzler, &
16
Marmar, 2005). While the majority of evidence has focused on the role of fatalism in chronic
disease prevention and treatment (see De Los Monteros & Gallo, 2011), recent evidence suggests
that it is related to substance use. In a sample of primarily non-Hispanic White undergraduate
college students, fatalism sufficiently predicted smokers from non-smokers (Henson, Carey,
Carey, & Maisto, 2006) and Franklin and colleagues (2007) showed that religious fatalism was
predictive of several negative health behaviors including substance use. Yet, the majority of
evidence to date on the relation between fatalism and substance use has not examined in
Hispanic populations exclusively or investigated longitudinally.
Previous work examining the role of these cultural values and traits simultaneously has
produced interesting findings. For instance, one cross-sectional study noted that fatalism was not
protective for alcohol, marijuana or tobacco use while respeto was protective for use of all three
substances and fatalism was a risk factor for marijuana and cigarette, but not alcohol, use (Soto
et al., 2009). Shih and colleagues (2012) examined familism and respeto (operationalized as
respect and honor for one’s parents) concurrently and found that relationships with alcohol
expectancies and initiation differed considerably between ethnic groups. Yet, there has not been
any work documenting how familism, respeto and fatalism operate among substance users and
whether or not it prevents escalation to problematic levels. Such information can be useful when
attempting to develop culturally sensitive secondary prevention programs targeting substance
misuse, in particular.
Perceived discrimination and substance use. Perceived discrimination, the belief that
negative social interactions are the result of social group membership, has been documented
extensively among minority groups over the last three decades (Telles & Murgia, 1990; Feagin,
1991; Perez, Fortuna, & Alegria, 2008). The health impact of perceived discrimination has been
17
well studied suggesting that perceived discrimination is associated with heightened levels of
depression and psychological distress (Dion & Earn, 1975; Finch, Kolody, & Vega, 2000;
Umana-Taylor & Updegraff, 2007), lower levels of self-esteem (Verkuyten, 1998; Major, Kaiser,
O’Brien, & McCoy, 2007), increased substance use behavior (Gibbons, Gerrard, Cleveland,
Wills, & Brody, 2004; Okamoto, Ritt-Olsen, Soto, Baezconde-Garbanati, & Unger, 2009), and
other negative health behaviors (for review, see Pascoe & Smart Richman, 2009; Schmitt,
Branscombe, Postmes, & Garcia, 2014). National estimates show that 30% of Hispanics report
some form of perceived discrimination (Perez, Fortuna, & Alegria, 2008). Recent immigrants or
children of immigrants, for instance, are particularly vulnerable to experiencing perceived
discrimination due to, among other factors, limited English proficiency and unfamiliarity with
living in a multiethnic society structured like the United States. However, a dearth of research
had focused on Hispanics health outcomes (Viruell-Fuentes, 2007) relative to African
Americans, in particular, until recently.
Research with U.S.-born Hispanic youth has suggested that perceived discrimination is
positively and prospectively associated with substance use attitudes and behavior through
adolescence and emerging adulthood (Okamoto et al., 2009; Unger, Schwartz, Huh, Soto, &
Baezconde-Garbanati, 2014), and work with immigrant Hispanic youth has produced similar
findings (Tran, Lee, & Burgess, 2010).
A limitation in the majority of research on the role of perceived discrimination and
negative health behaviors is that perceived discrimination is often examined in solidarity without
the presence of theoretically meaningful covariates in the statistical models. Thus, while
statistically significant associations may be observed, the findings may be offset by small effect
sizes. Therefore, it is important to examine perceived discrimination in a framework with other
18
external and internal cultural factors. For instance, while Cheng and Mallinckrodt (2015)
documented a prospective relationship between perceived discrimination and alcohol use
problems, the statistical model did not control for peer influence, psychological risk factors (e.g.,
drinking motives/expectancies, depression, anxiety) or other potentially relevant cultural factors
such as ethnic identification or salient cultural values such as familism. The resulting unadjusted
results may not be robust to the concurrent assessment of other important covariates of
problematic alcohol use.
In another study researchers created a single latent factor comprised of perceived
discrimination, bicultural stress and negative context of reception (Schwartz et al., 2014) and
found that it predicted future drunkenness and marijuana use for immigrant Hispanic
adolescents. The authors argue that this finding shows these constructs contribute to a stable
measure of “cultural stress” and that the additive effects of cultural stressors contribute to
substance use. However, with no comparison of how these factors influenced substance use
independently, it is impossible to deduce whether one type of “cultural stress” might be more
significantly related to these outcomes than another.
A goal of this work is to partially fill this gap by examining perceived discrimination in a
larger sociocultural framework that incorporates ethnic identity, depressive symptomology and
peer alcohol use in statistical models and to improve our knowledge of the impact that perceived
discrimination has on alcohol use problems for Hispanic emerging adults.
Exploring the role of ethnic identity in alcohol use and misuse
Personal identity and ethnic, or cultural, identity are conceptually independent as
personal identity reflects goals, attitudes and beliefs that may or may not be related to ideals of a
social group whereas ethnic identity reflects a social identity that represents the values and
19
beliefs explicitly tied to members of one’s social group. Ethnic identity is the subjective sense of
belonging to a social group that shares similar demographic features, beliefs and attitudes
(Phinney, 1990). Over the course of adolescence and adulthood, ethnic identity develops in
response to the dynamic social, psychological and contextual changes experienced as an
individual matures (Marcia, Waterman, Matteson, Archer, & Orlofsky, 1993; Phinney et al.,
2001). Schwartz and colleagues (2010) have described ethnic identity as an aspect of the
acculturation process. They argue that the focus on an individual’s attachment to the culture of
origin, independent of perceptions of the host culture, may protect individuals from culturally
related stressors (e.g., perceived discrimination) although this has only been explored
theoretically. Ethnic identity may be particularly salient for minority groups as connection and
confidence in one’s heritage group may ameliorate or negate feelings of insecurity or confusion
(Phinney et al., 2001) and has been previously shown to be a protective factor against substance
use (Brook et al., 1998; Brook & Pahl, 2005; Williams, Aiyer, Durkee, & Tolan, 2014) though
the majority of evidence comes from African-American samples. National data also suggests that
higher ethnic identity scores are related to a lower chance of perceiving—or at least reporting—
discrimination (Perez, Fortuna, & Alegria, 2008). A goal of the present investigation explores the
role of ethnic identity as a buffer against perceived discrimination in predicting frequency of
alcohol use and the experience of related positive and negative consequences among Hispanic
emerging adults.
As part of this investigation, ethnic identity is explored as an independent protective
factor, and effect modifier of perceived discrimination, in predicting alcohol related negative
consequences. While identity formation may not be complete by emerging adulthood, it is likely
20
that a stronger affiliation with cultural mechanisms that are empirically protective from alcohol
and drug use may buffer the impact of other risk factors, such as perceived discrimination.
Negative alcohol use consequences and other health/behavioral problems. Recent work
suggests that negative substance use consequences may be just as effective as traditional drug
use measures at predicting externalizing problems, such as being arrested or carrying a weapon,
or engaging in risky sexual behaviors such as not using a condom at the last sexual encounter
(Grigsby et al., 2014). This particular study also observed a difference in the relationship
between substance use constructs and depressive symptomology. Specifically, higher levels of
drug use consequences had a stronger association with depressive symptomology than low levels
of consequences whereas lower levels of drug use frequency had a stronger association with
depressive symptoms than high levels of drug use frequency. This finding suggests that problem
use may serve as a useful predictor of other problem behaviors and may assist in the
identification of internalizing and externalizing problems to a different degree than typical
measures of substance use are able to capture due, in part, to the methodological limitations of
substance use measurement discussed earlier.
In addition to these general findings, an existing body of literature has documented the
relationship between alcohol problems and aggressive behavior, with an emphasis on intimate
partner violence (Foran & O’Leary, 2008a). In several studies, alcohol problem use has been
found to be independently related to intimate partner violence (for review, see Foran & O’Leary,
2008a), and such findings raise important questions about the impact of problem alcohol use on
other health related behaviors. For instance, problem drinkers may represent a unique subset of
alcohol users with greater physical or psychological dependence on alcohol—which would
explain their continued use while incurring negative outcomes. Alternatively, problem users may
21
perceive that alcohol use results in more positive than negative outcomes compared to regular
drinkers and continue to use at levels that lead to negative consequences. This mindset may carry
over to other negative health behaviors and promote individuals to continue engaging in
aggressive behaviors, unprotected sex and so on without considering the immediate or long-term
consequences that may result. Nevertheless, more work is needed to understand the mechanism
that links negative health behaviors together in order to develop efficacious prevention programs
that can reduce problems in multiple areas of one’s life.
Theoretical framework
The Theory of Triadic Influence (TTI; Flay & Petraitis, 1994) is used as a heuristic
framework to guide the global research questions for the present studies. The TTI is
advantageous as a theoretical model as it incorporates elements of many existing health behavior
theories and organizes the types of influences on behaviors into streams while discussing the
extent to which different factors influence behavior as ranging from very proximal to distal and
ultimate. The TTI describes three specific streams, or types, of influence on behavior:
cultural/attitudinal, social/normative and biological/intrapersonal.
The cultural/attitudinal stream describes how broad sociocultural factors indirectly shape
attitudes through their impact on knowledge and beliefs while the social/normative stream
explains how the immediate social environment shapes normative beliefs through social bonding
and social learning. Finally, the biological/intrapersonal stream describes the contributions of
sense of self (i.e., identity) and social competence contributes to the development of self-
efficacy. The contribution of individual factors located within any of these streams can be
described by their level of influence organized as tiers that include ultimate influences (broad and
relatively stable background and environment level factors), distal influences commonly
described by two subgroups (social person nexus (where ultimate causes interact to form
22
personally relevant, but still general, relationships, beliefs and sense of self, for example),
expectancy-value (where factors on the social person nexus become more relevant to the
behavior of interest)), and proximal influences (immediate precursors of a behavior that are
generally under control of the individual). Of note, proximal predictors have consistently been
shown to be robust predictors of behavior (Flay et al., 2009).
The TTI is flexible in that the model was designed to expect influences from multiple
streams of influence to interact and have a combined effect on behavior. With an exhaustive list
of possible causal factors and applicability of the model to explain initial and continued
behaviors, the TTI is a desirable model for explaining alcohol use involvement among other
health behaviors. Of interest, many studies of substance use generally tend to focus on predictors
from the social/normative (for review see, Borsari & Carey, 2001; Stone et al., 2012) and
biological/intrapersonal streams of influence (for review, see Donovan, 2004; Saraceno, Munafó,
Heron, Craddock, & Van Den Bree, 2009).
An objective of the present empirical inquiry is to examine influences from the
cultural/attitudinal stream that are less commonly examined in substance use research. This work
focuses on unique and salient sociocultural variables among Hispanics, in particular. In order to
examine the contribution of cultural/attitudinal variables within the TTI framework the statistical
models will be adjusted to account for other theoretically and empirically meaningful factors
from other streams of influence that are implicated as predictors of, or risk factors for, substance
use behavior. Specifically, all statistical models in the present investigation will control for peer
alcohol use and depressive symptomology.
Theoretical and empirical rationale for selection of covariates
23
Previous work has documented the robust relationship between peer use and
experimentation, regular use and misuse of different substances (for review, see Leung,
Toumbourou, & Hemphill, 2014). The prevailing theories explaining the role peers serve in
substance use commonly propose one of two reasons for this consistent finding across
populations and disciplines studying substance use: peer selection effects and peer influence
(Hoffman, Sussman, Unger, & Valente, 2007). The “peer selection” effect is described as
selecting friends who exhibit similar behavioral tendencies whereas “peer influence” suggests
that social networks exert normative pressures on individuals to adopt or maintain behaviors to
fit in. Regardless of the mechanism, many prevention strategies for adolescents have been
designed to buffer against the negative influences of peers or enhance resilience and promote
friendships based on prosocial activities and interests. Peers serve an important role in substance
use behavior as they influence perceived norms and acceptability of such behaviors, can
undermine refusal skill self-efficacy skills and impact perceptions of the personal and social
consequences of substance use. In all, peers serve a quintessential role in the social influence
stream during adolescence and young adulthood given their ability to shape perceptions and
beliefs regarding the social acceptability of substance use
Internalizing problems—especially depressive symptomology—are also prevalent in
community and clinical samples reporting alcohol or drug use and misuse (Conner, Pinquart, &
Gamble, 2009; Darke et al., 2009). Depressive symptomology has been observed as a predictor
of substance use in multiple community samples examining experimental and regular substance
use during adolescence (McCarty et al., 2012; Maslowsky, Schulenberg & Zucker, 2014) and
early adulthood (Stone et al., 2012; Snyder & Rubenstein, 2014). Despite the strong possibility
of reciprocal causality (Boden & Fergusson, 2011), depression is consistently associated with
24
substance use behavior and likely reflects common genetic and environmental mechanism (i.e.,
stressors) that result in internalizing and externalizing problems (Edwards et al., 2011).
Depressive symptomology is an important theoretical covariate given its propensity to impede
the development of refusal self-efficacy skills in situations where behaviors, such as alcohol use,
can serve as a maladaptive coping mechanism for internal stress experienced by an individual.
By controlling for empirically relevant variables in the social and biological/intrapersonal
streams, this work will have stronger theoretical implications should meaningful relationships be
revealed between cultural factors and alcohol use consequences. Depressive symptomology and
peer alcohol use were assessed at each wave of the Project RED study, and while other important
covariates of alcohol use and misuse behavior exist in the social and biological/intrapersonal
streams including, but not limited to: stress, personality factors, drug use expectancies, and
family history of alcohol/drug abuse (Borsari & Carey, 2001; Carey et al., 2007; Mallett et al.,
2013); the Project RED data does not include measures for these constructs to investigate them
as covariates for the studies described below.
Study Aims
Study 1: Changes in familism, respeto and fatalism during emerging adulthood and its
relationship with negative alcohol use consequences in Hispanic emerging adults
To date, research on cultural values and their relation to alcohol use in Hispanic groups
has typically been limited by examining relationships cross-sectionally or independently. The
goal of study one is to partially fill this gap by conducting a longitudinal examination of three
cultural factors (familism, respeto and fatalism) while controlling for ethnic identity in relation to
negative alcohol use consequences in a sample of Hispanic emerging adults. Using a parallel
process latent growth model, I examine the relationship between these constructs over four
25
waves of data while controlling for theoretically meaningful covariates including peer alcohol
use and depressive symptomology (Figure 2).
This is an important goal as the findings will provide initial evidence regarding the role
of cultural values in alcohol misuse as most emerging adults initiate alcohol use during
adolescence and are at higher risk for dependence and abuse during the young adult life stage
(SAMHSA, 2013). As such, these findings will assist researchers in identifying modifiable
characteristics in culturally sensitive secondary prevention programs aimed a preventing alcohol
misuse and abuse with Hispanic emerging adults.
Study 2: Perceived discrimination predicts negative and positive alcohol use consequences, but
not alcohol use frequency, among Hispanic emerging adults
While little research exists documenting the association between perceived
discrimination and problematic alcohol use, emerging evidence suggests that discrimination is
positively associated with use and misuse of alcohol and drugs. However, it is unclear if
perceived discrimination has a similar association with the amount (frequency) of alcohol use
and the level of problematic use (negative consequences) experienced by Hispanic emerging
adults. Additionally, less is known about factors that can potentially buffer these harmful
relationships and I explore if and how ethnic identity may buffer the effect of perceived
discrimination.
This study will be an extension of the previous study and serves three purposes. First,
perceived discrimination is examined in relation to alcohol consequences with frequency of use
serving as a mediator. Second, this study will explore if and how ethnic identity modifies this
relationship by examining it as a moderator between perceived discrimination with a) frequency
of alcohol use and b) frequency of negative alcohol use consequences. Finally, I examine
26
whether these relationships operate differentially when negative or positive consequences are
measured as the final outcome (Figure 3). This may elucidate important differences between
individuals who experience discrimination, use alcohol and experience positive or negative
outcomes from their alcohol use.
Study 3: Quantity of alcohol use problems modifies the effect of perceived discrimination on
physical intimate partner violence perpetration for Hispanic emerging adults
A strong relationship between intimate partner violence with alcohol use or problem use
has been documented in the research literature (Foran & O’Leary, 2008a). The next step for
prevention scientists is to identify common risk and protective factors that can be targeted in
prevention and intervention programs. For Hispanic populations, the role of perceived
discrimination may be one such target as previous work has linked it with alcohol use and IPV
independently (Sanderson, Coker, Roberts, Tortolero, & Reininger, 2004; Forster et al., in
preparation; Okamoto et al., 2009; Unger, Schwartz, Huh, Soto, & Baezconde-Garbanati, 2014).
In order to examine this possible interrelationship, study three explores whether problem alcohol
use moderates the relationship between perceived discrimination and intimate partner violence
victimization and perpetration (Figure 4).
27
CHAPTER 2: STUDY METHODS
Participants and Procedure
Data was provided from participants who participated in the emerging adult Project RED
(Retiendo y Entendiendo Diversidad Para Salud) study, a longitudinal examination of
acculturation patterns and substance use among Hispanics in Southern California. Initial
enrollment took place when participants were in high school and details on recruitment and study
procedures can be found elsewhere (Unger, Ritt-Olsen, Wagner, Soto, & Baezconde-Garbanati,
2009). Between 2010 and 2012, the study team attempted to re-contact participants who self
identified as Hispanic, Latino or Latina, Mexican, Mexican American, Chicano or Chicana,
Central American, South American, Mestizo, La Raza, or Spanish on the high school surveys to
take part in a series of surveys on their experiences as emerging adults. Research assistants sent
letters to respondents’ last known addresses and invited them to visit a Web site or call a toll-free
phone number to participate in the study. If participants could not be contacted with the
information they had provided in high school, staff searched for them online using publicly
available search engines and social networking sites. These tracking procedures resulted in 2,151
participants with valid contact information. A total of 1,390 (65%) participants provided verbal
consent over the phone, or read the consent script online and clicked a button to indicate consent,
and participated in initial survey of the emerging adulthood study.
Participants completed surveys on an annual basis by phone or online and were
compensated $20 for completing the survey and $3 for updating their contact information.
Participants completed survey measures annually in 2011-2012, 2013, 2014, and 2015-2016.
Wave four data collection was completed in January 2016. Study one uses data from all four
waves of data collection, study two uses data from waves two and three and the final
investigation uses data from the final two waves of data collection (waves 3 and 4). As a result of
28
measuring different constructs across different time points from the Project RED data, it should
be noted that the sample sizes of each study vary as a result.
Attrition analysis
Attrition analyses were performed due to the large proportion of participants lost to
follow up between the high school and emerging adulthood survey protocols. For the overall
sample, participants were more likely to be lost to follow-up if they were male (p<0.05) or
reported binge drinking in high school (p<0.05). As the present analyses focus on alcohol users,
we re-ran the attrition analysis to investigate whether alcohol users were more likely to be lost to
follow-up as a function of the main predictors investigated in these studies.
Results indicate that, among alcohol users, attrition was not significantly related to level
of familism (p=0.63), respeto (p=0.54), fatalism (p=0.08), perceived discrimination (p=0.40), or
cultural identity (p=0.18). However, among those reporting alcohol use in high school, higher
frequency of negative consequences was associated with being lost to follow-up between the
high school and emerging adulthood studies (p<0.01). As such, the resulting sample that
provided data during emerging adulthood is likely a lower risk subsample of the original Project
RED cohort. This limits the generalizability of the findings to lower risk samples of Hispanic
emerging adult alcohol users.
Non-alcohol users were excluded from the present analyses, as the focus of the studies
was to explore alcohol related consequences. Multiple imputation and other missing data
strategies were not used to estimate negative—or positive—consequences from alcohol use
among individuals reporting no alcohol use. However, this may exclude former drinkers
experiencing alcohol use consequences in adolescence that have quit drinking in young
adulthood. Exploration of the Project RED data evidences that among participants with alcohol
use data (n=942), the majority began using alcohol during emerging adulthood (n=344, 36.5%)
29
followed by those who used during adolescence and EA (n=298, 31.6%), and those abstaining at
both time points (n=205, 21.8%). Only 95 (10.1%) reported using alcohol in adolescence but not
in emerging adulthood. Given these trends in alcohol use behavior, the present studies excluded
non-alcohol users from the analysis in lieu of imputing the outcome (alcohol related
consequences) for such individuals.
Measures
Perceived discrimination (wave 1 α = 0.95; wave 2 α = 0.98; wave 3 α = 0.97). Perceived
discrimination (Guyll, Matthews & Bromberger, 2001) is a primary predictor of interest across
these studies and was measured with 10 items at all study waves to assess the degree to which
participants felt they were treated differently due to their racial/ethnic group membership.
Sample items include “People act as if they are better than you” and “You and your family
members are called names or insulted.” Responses ranged from 0 “never” to 3 “often” and were
summed such that higher scores indicate higher levels of perceived discrimination.
Ethnic identity (wave 1 α = 0.92; wave 3 α = 0.89). The 12 item ethnic identity scale
developed by Phinney (1992) was used to measure ethnic identity in EA waves 1 and 3 and
serves as a moderator of interest for study two. Participants are presented statements such as “I
have a clear sense of my ethnic background and what it means to me” and “I am happy that I am
a member of the group I belong to” and asked whether they strongly disagree (0), disagree (1),
agree (3), or strongly agree (4) with each statement. Responses are summed to create an score
representing the degree to which an individual identifies with their ethnic or cultural heritage
group where higher scores represent stronger identification.
Familism (wave 1 α = 0.93; wave 2 α = 0.94; wave 3 α = 0.92; wave 4 α = 0.94).
Familism was assessed with four items with four response options: “definitely not,” “probably
not,” “probably yes,” and “definitely yes.” Sample items include “I expect my relatives to help
30
me when I need them” and “When a family makes an important decision, they should talk about
it with their close relatives.” Responses were summed so that higher values indicated higher
levels of familism.
Respeto (wave 1 α = 0.88; wave 2 α = 0.95; wave 3 α = 0.94; wave 4 α = 0.95). Respeto
was assessed with four items with four response options: “definitely not,” “probably not,”
“probably yes,” and “definitely yes.” Sample items include “I will take care of my parents when
they are old” and “It is important to honor my parents.” Responses were summed so that higher
values indicated higher levels of respeto.
Fatalism (wave 1 α = 0.81; wave 2 α = 0.90; wave 3 α = 0.91; wave 4 α = 0.93). Fatalism
was assessed with four items with response options: “definitely not,” “probably not,” “probably
yes,” and “definitely yes.” Sample items include “I live for today because I don’t know what will
happen in the future” and “I don’t plan ahead because most things in life are a matter of luck.”
Responses were summed so that higher values indicated higher levels of fatalism.
Alcohol use frequency. We assessed frequency of alcohol use with a one item question
asking about past month use. Participants were asked, “During the last 30 days, how many days
have you had at least one drink?” with responses ranging from 0 to 30 days. This variable served
as a mediator of interest for study two.
Negative alcohol use consequences. The outcomes of interest were derived from a subset
of seven items from the Rutger’s Alcohol Problem Index (RAPI; White & Labouve, 1989) used
to assess alcohol use consequences for the current study. For study one, the original scoring
measure for the RAPI was used where scores from a Likert scale measuring frequency of
occurrence of each alcohol-related consequence were summed to develop an alcohol use
problems score. For studies two and three, a composite index was used where the total number of
31
consequences experienced served as an outcome for a negative binomial regression and as a
predictor of IPV victimization and perpetration, respectively. Research has demonstrated the
usefulness of scoring the RAPI items dichotomously (Martens, Neighbors, Dams-O’Connor,
Lee, & Larimer, 2007). Therefore, the RAPI was interpreted as a checklist in the latter studies,
and items were summed to create a composite score of the total number of consequences
experienced in the past 30 days.
Positive alcohol use consequences (wave 4 α = 0.92). The 14-item Positive Drinking
Consequences Questionnaire (PDCQ; Corbin, Morean & Benedict, 2008) was added to the
Project RED study on the EA wave 4 survey. Of note, the instructions were revised to ask
participants to think of positive events that occurred as a result of drinking alcohol or using other
drugs, but we limited the sample to only include alcohol users. Likert responses for the scale
were developed to mimic the possible responses for the RAPI measure. The PDCQ items were
summed to create a score of the total number of positive consequences from alcohol or drug use
experienced in the past 30 days.
Intimate Partner Violence (IPV) perpetration and victimization. The outcome of interest
was measured using the 20-item short form of the Revised Conflict Tactics Scale (Straus &
Douglas, 2004). The measure asks respondents to recall the number of acts of violence within an
intimate relationship for the previous 12-month period. The instrument has eight response
categories: (0 = has never happened, 1 = once in the past year, 2 = twice in the past year, 3 = 3-5
times, 4 = 6-10 times, 5 = 11-20 times, 6 = more than 20 times in the past year, 7 = happened
more than one year ago). We examined perpetration of physical (for example, “I pushed, shoved,
or slapped my partner”), psychological (for example, “I insulted, or swore, or shouted, or yelled
at my partner”) and sexual (for example, “I used force (like hitting, holding down or using
32
weapon) to make my partner have sex”) aggression as well as victimization of physical (for
example, “My partner pushed, shoved, or slapped me”), psychological (for example, “My partner
insulted, or swore, or shouted, or yelled at me”) and sexual (for example, “My partner used force
(like hitting, holding down or using weapon) to make me have sex”) aggression. Perpetration and
victimization of each IPV type were examined separately as dichotomous variables where
respondents were categorized as no (did not experience IPV perpetration or victimization) or yes
(did experience IPV perpetration or victimization).
Study 1 covariates
Gender was coded 0=female and 1=male for analysis and served as a covariate that was
used to stratify the sample. Between-person covariates for the present analysis include peer
alcohol use, depression symptomology, ethnic identity and alcohol use frequency. Peer alcohol
use was measured by asking participants to report the number of close friends who used alcohol.
Possible responses ranged from 0 (zero close friends use) to 5 (all five close friends use).
Depression symptomology was measured with a brief version validated for use in Spanish
speaking populations (Kohout, Berkman, Evans, & Cornoni-Huntley, 1993; Grzywacz et al.,
2006) of the original 20-item Center for Epidemiological Studies – Depression (CES-D) scale
(Radloff, 1977) that was administered since the EA wave 1 assessment. Items were reverse
coded, when necessary, to create a linear measure of depression.
Study 2 covariates
Gender was coded as 0 for females and 1 for males. Peer alcohol use and depressive
symptomology—using the same measures as in study one—are controlled for in this analysis. In
addition, the analysis controlled for adverse childhood events (ACEs; Anda et al., 1999) given
their strong theoretical and empirical relationship with IPV (Black, Sussman, & Unger, 2010;
33
Ehrensaft et al., 2003; Renner & Slack, 2006; Roberts et al., 2011). ACEs were measured as
composite scores capturing the average frequency of childhood physical abuse, verbal abuse, and
inter-parental violence exposure.
Study 3 covariates
Covariates included gender, peer alcohol use, and depressive symptomology. Peer
alcohol use and depressive symptomology serve as theoretical covariates. Ethnic identity was
assessed as a covariate and moderator of the effect of perceived discrimination on positive and
negative consequences of alcohol use.
34
CHAPTER 3: CHANGES IN FAMILISM, RESPETO AND FATALISM DURING EMERGING ADULTHOOD
AND ITS RELATIONSHIP WITH NEGATIVE ALCOHOL USE CONSEQUENCES IN HISPANIC EMERGING
ADULTS: DIFFERENCES BY GENDER
Background and Rationale
Among the Hispanic population in the United States, early adulthood marks an increase
in substance use frequency, related negative consequences and incidence of abuse or dependence
at rates that are often disproportionately higher than other racial/ethnic groups with the exception
of Native Americans (Chen, Dufour & Yi, 2005; Witbrodt, Mulia, Zemore, & Kerr, 2014). While
alcohol and drug use was originally believed to be less harmful—at the neurobiological level—
during this life stage relative to adolescence, recent evidence has suggested that the brain is not
fully formed by early adulthood (Lebel & Beaulieu, 2011) and may suffer long-term structural
and functional damage. As such, it is imperative that public health researchers identify protective
factors that can offset alcohol misuse, at least, and delay escalation to clinical levels of misuse
among current users.
To achieve such a goal, researchers must improve their methodology for studying alcohol
use. For most, but not all, alcohol use begins in adolescence and it would seem logical to explore
factors related to frequency or quantity of alcohol use when examining emerging adult
populations. Most alcohol use research has adopted this tact, but researchers might be
overlooking important trends in alcohol use behavior that cannot be captured in measures of past
week, month, yearly, or lifetime use. There are subsets of alcohol users that experience proximal
and deleterious events due to their alcohol or drug use, that is not solely a function of substance
use frequency, termed problem users. Problem users experience negative consequences from
substance use such as blacking out, getting into fights with others or neglecting day-to-day
responsibilities and continue to use alcohol or drugs. This manifestation of misuse may be useful
in identifying individuals that are escalating towards alcohol and drug use disorders, and
35
represents a unique opportunity for researchers to intervene and prevent the need for clinical
evaluation or intervention. To date, the majority of research has focused on risk factors for high
frequency use and problem use—especially in the alcohol use literature—including peer use,
family history of misuse and certain personality traits (for review, see Mallett et al., 2013;
Grigsby et al., 2016). Conversely, there has been a paucity of research focusing on the
identification of protective factors in emerging adult alcohol use behavior, such as the role of
distal cultural variables.
In Hispanic populations, a source of hardiness and resilience from alcohol or drug use in
emerging adulthood may be found in salient cultural values and traits. Familism, respeto and
fatalism have been the most frequently explored values and traits in Hispanic populations in
reference to health behavior and serve as the focal point of the present investigation. Familism is
described as a sense of duty and responsibility to the family unit while respeto measures an
individual’s respect for others based on age, gender and authority with a particular emphasis on
duty and respect for one’s parents. While these constructs measure distinct, but related processes,
they both measure underlying facets of global family functioning. As such, we would expect
familism and respeto to be protective factors as studies with adolescent, multiethnic samples
have demonstrated that positive family functioning is inversely associated with alcohol or drug
use (Cordova, Heinze, Mistry, Hsieh, Stoddard, et al., 2014; Cordova, Huang, Lally, Estrada, &
Prado, 2014; Wagner et al., 2010). Fatalism, on the other hand, has been frequently explored as a
risk factor as this cultural trait captures the belief that future events are controlled by external
elements such as fate, chance or divine intervention. While more work has examined this factor
in reference to disease screening and treatment adherence (for review, see De Los Monteros &
Gallo, 2011; Walker et al., 2012) there is evidence that higher levels of fatalism are associated
36
with increased substance use behavior (Somlai et al., 2000; Soto et al., 2011). Higher levels of
fatalism may be more salient in Hispanic cultures where belief in a higher power is prominent
(Karvinen & Carr, 2014) resulting in lower internal locus of control; higher levels of fatalism
may also be an indicator of underdeveloped coping skills or lack of resilience to stressful life
events.
Important gender differences have been observed in Hispanic populations that may
influence the relationship between these values and traits with substance use behavior. For
example, Hispanic females have been documented as having higher levels of perceived
importance of family (Rodriguez, Mira, Paez, & Meyers, 2007) and greater parental
communication, family involvement, and a general sense of familism compared to males (Lac et
al., 2011). This may be due to differential gender socialization (Zayas, Lester, Cabassa, &
Fortuna, 2005) where boys are given more liberty to explore roles outside the household
compared to girls. In turn, girls may become more sensitive to family conflicts or problems
(Zayas et al., 2005), perhaps due to the expectation that they will be future caregivers, resulting
in greater depression or stress (Lorenzo-Blanco, Unger, Baezconde-Garbanati, Ritt-Olson, &
Soto, 2012). This could lead, for example, to increased alcohol use or misuse as a coping
mechanism, although this has not been explored empirically. A heightened respect for authority
figures (i.e., respeto), and parents specifically, may be more prominent for females than for
males as well (Zayas et al., 2000).
These findings reverberate earlier discussions on gender roles and alcohol use and
problems (Nolen-Hoeksema, 2004) where males who embody “macho” beliefs or attitudes
experience more alcohol problems and females who retain traditional female role attitudes use
less alcohol, generally. As such, alcohol use may be an indicator of defiance in some cases, but
37
not others, and result in differential alcohol use trajectories across genders. Finally, there may be
gender differences in fatalistic beliefs that can translate to differences in health behavior
(Franklin et al., 2007), but this has not been examined in relation to alcohol use behavior,
specifically.
There have been some limitations to these findings that warrant discussion. First, these
cultural factors may have a differential impact on substance use or misuse between adolescence
and emerging adulthood, A preliminary analysis with the Project RED sample (Supplemental
Table 1) indicates that the respeto and fatalism have a stronger relationship with past 30-day
alcohol use in adolescence than in EA.
Supplemental Table 1. Past 30-day alcohol use regressed on familism, respeto and fatalism in
11
th
grade (adolescence) and wave one of the emerging adulthood survey.
(a) 11
th
grade Alcohol use
β SE
Familism -0.02 0.01
Respeto -0.09*** 0.02
Fatalism 0.04*** 0.01
R
2
= 0.06
(b) EA β SE
Familism 0.001 0.01
Respeto -0.02^ 0.01
Fatalism 0.02* 0.01
R
2
= 0.01
Note: β = unstandardized beta and SE = standard error. *p<0.05, **p<0.01, ***p<0.001,
^p=0.057
Following adjustment for peer alcohol use (Supplemental Table 2), the associations
between these cultural values and past 30-day alcohol use weaken during adolescence. Peers also
explain a larger proportion of the variance in alcohol use during adolescence. However, the
significant association between fatalism and past 30-day alcohol use remains among emerging
adults.
38
Supplemental Table 2. Past 30-day alcohol use regressed on familism, respeto and fatalism
adjusting for peer use in 11
th
grade (adolescence) and wave one of the emerging adulthood
survey.
(a) 11
th
grade Alcohol use
β SE
Familism -0.02 0.01
Respeto -0.08*** 0.02
Fatalism 0.02* 0.01
R
2
= 0.21
(b) EA β SE
Familism -0.004 0.01
Respeto -0.02^ 0.01
Fatalism 0.02* 0.01
R
2
= 0.13
Note: β = unstandardized beta and SE = standard error. *p<0.05, **p<0.01, ***p<0.001,
^p=0.055
Second, the examination of the protective effects that cultural values have on substance use
behavior has been limited to the study of adolescent or college populations. Despite knowledge
that substance use behavior may be more risky during emerging adulthood—given higher
estimates of abuse and dependence during this life stage compared to any other life stage—the
majority of work has focused on a small proportion of alcohol use behavior (i.e., initiation or
past 30 day use) or focused on specific subgroups (i.e., college students).
Third, more work is needed to explore longitudinal changes in these cultural traits and
values as it relates to identity development. Personal and ethnic identity is not fully formed by
adolescence (Phinney, 2006; Phinney & Ong, 2007) and may explain why influence by peer
behaviors is stronger relative to one’s attachment to distal cultural values, especially in
adolescence. Furthermore, as individuals grow older their attachment to these values may change
as a result of their cultural identity formation that can take similar developmental trajectories as
personal identity (i.e., diffusion, foreclosure, moratorium, achievement). While we do not
formally address this issue here, this work contributes to the existing literature on the relation of
39
cultural factors and substance use behavior by examining longitudinal associations of familism,
respeto and fatalism with alcohol use and misuse while controlling for other relevant covariates
including peer alcohol use, sociocultural stressors (i.e., perceived discrimination) and level of
ethnic identity.
Current study
The current gaps in the alcohol use literature may be limiting the ability of prevention
scientists to appraise and incorporate culturally relevant intervention strategies with emerging
adult populations. Therefore, the present study hopes to partially fill this gap by examining the
longitudinal associations between changes in three cultural values and traits (familism, respeto
and fatalism) with negative alcohol use consequences.
The goal of this research is to better inform prevention scientists in the design of primary
and secondary prevention programs targeting Hispanic emerging adult populations. Based on
data collected annually for four consecutive years in a community sample of emerging adult
Hispanic adolescents, it is hypothesized that:
1) Initial levels of familism and respeto will be negatively associated with initial levels
(intercept) of alcohol use frequency and related negative consequences while fatalism
will show a positive association. Initial levels will have a similar association with the rate
of change (slope) of alcohol use frequency and related negative consequences.
2) Increases in the slope of familism and respeto over time will be negatively associated
with rate of change (slope) in alcohol use frequency and related negative consequences
while positive growth in fatalism will be positively associated with the slope of alcohol
use frequency and related negative consequences.
40
3) It is also hypothesized that gender will moderate the aforementioned relationships such
that the inverse relationship of familism and respeto will be stronger for females than
males and the positive association of fatalism will be stronger for females than males.
Analysis Plan
A parallel process latent growth model (LGM; CITE) was used to examine the
relationships between changes in cultural values over time with change in alcohol use frequency
and related negative consequences for the sample. Analyses were completed in three steps. First,
descriptive statistics were calculated for the study variables and compared between males and
females to examine whether differences existed warranting multiple group analysis. Second, in
preparation for the main analysis, univariate growth curve models were fit to the predictors
(respeto, familism, fatalism) of interest and the outcomes (alcohol use frequency and alcohol
related negative consequences) to examine the intercept and mean trajectory of each variable,
separately, without the presence of covariates. Third, a parallel process model was run to
examine whether the initial status (intercept) and rate of change (slope) of the predictors was
associated with the initial status and slope of the outcome (negative alcohol use consequences).
Correlational pathways were used to explore relationships among variables given that events
occurred contemporaneously. Full Information Maximum Likelihood (FIML) was used to handle
missing data in the statistical models and the GROUPING command in Mplus (version 7) was
used to explore multiple group analyses. Chi-square difference tests compared model fit statistics
to determine whether constraints should be retained on paths in the model. Alcohol use
frequency and alcohol related negative consequences were explored as outcomes of interest in
separate statistical models. Ethnic identity, depression (CES-D score), and alcohol use frequency
were entered as covariates in the final parallel process models.
41
Model fit was assessed with several indices. The comparative fit index (CFI) indicates the
degree to which the specified model provides a better fit to the data than a null model with no
paths or latent variables. A CFI value of 0.90 or greater indicates acceptable fit (Bentler, 1990;
Postmes & Branscombe, 2002). The root mean square error of approximation (RMSEA)
indicates the extent to which the covariance structure specified in the model deviates from the
covariance structure observed in the data, and values lower than 0.08 indicate acceptable model
fit (Brown & Cudeck, 1993). The chi-square statistic tests the null hypothesis of perfect fit to the
data but is considered less reliable, due to inflation, as a result of larger samples and complex
models (Powell & Schaffer, 2001) and is not presented here. It is worth noting that structural
equation modeling and its extensions (e.g., growth curve and parallel process models) are a type
of confirmatory analysis. As such, fit indices are only useful for ascertaining the fit of a specific
model to the data. They do not identify the best fitting model or rule out alternative models that
may explain the data as well as, or better than, the specified model (Tomarken & Waller, 2003).
Analyses were completed using Stata version 14 (Stata Corp., 2014) and Mplus version 7
(Muthen & Muthen, 2014).
Results
Descriptive statistics for study variables
Of the 1,089 participants who completed all four annual surveys in the Project RED EA
study, 417 (38.2%) reported alcohol use at all four waves and constituted the analytic sample for
the present study. Of those 417, approximately 49.6% (n=207) are female. Study 1 Table 1
provides descriptive statistics of the study variables for the analytic sample separately by gender
and for the aggregate sample.
Females had significantly higher scores on the CES-D measure of depression (t=4.22,
p<0.001) than males. Males, relative to females, reported having more close friends that use
42
alcohol (t=-2.51, p<0.05), higher average frequency of past 30-day alcohol use (t=-5.47,
p<0.001) and more alcohol use consequences at every annual assessment (Study 1 Table 1).
Given the gender differences in the outcome of interest, multiple group analyses were performed
to examine differences in growth trajectories and associations between constructs by gender.
Univariate growth models
Univariate growth models were constructed individually for the three predictors of
interest (respeto, familism, fatalism) and for the outcomes (alcohol use frequency and negative
alcohol use consequences). In the aggregate sample, the univariate models all showed acceptable
fit when growth was modeled linearly (Study 1, Table 2). A quadratic model was explored, but
did not produce better model fit. Of the cultural values, there was only statistically significant
change observed in the familism (M=-0.15, p<0.001) and respeto (M=-0.09, p<0.01) constructs.
Fatalism did not change significantly over time for the aggregate sample, and was modeled using
the initial status value (wave 1 fatalism score). There was also no statistically significant
variance in the slopes of any predictor suggesting that the sample changed, on average, at a
similar rate. However, there was significant variance in the initial status for all variables in the
analysis. Both alcohol use frequency and negative alcohol use consequences showed statistically
meaningful change over time and the variation around the slope of alcohol use frequency was
statistically significant.
Growth trajectories in cultural traits among non-alcohol users. Among non-alcohol
using participants in the RED EA study (n=1,178) a similar pattern in growth trajectories was
observed. Specifically, there was a significant decrease in respeto and familism over time for
both males and females in addition to statistically non-significant change in fatalism over time
for fatalism. However, it was noted that significant variation in the slope was present for both
43
familism and respeto among non-drinkers whereas the variance around the slope was not
significant for alcohol users. A closer examination shows that this trend may be driven by female
non-alcohol users, in particular (Study 1, Table 3).
Measurement model
Alcohol use frequency. Guided by the results of the univariate growth models, the final
analytic model included growth factors for familism, respeto, and alcohol use frequency.
Covariates (peer alcohol use, depression, cultural identity) were entered into the model as time
invariant variables. The initial value for fatalism was used, as there was no significant change in
this construct over time. The final analytic model for alcohol use frequency had acceptable
model fit (CFI = 0.91, TLI = 0.89, RMSEA = 0.049, SRMR=0.068).
Alcohol related negative consequences. The final analytic model for alcohol related
negative consequences was identical to the model used for alcohol use frequency with the
exception of the growth factor for alcohol use frequency being entered as an additional covariate
in the analysis. The final analytic model for alcohol related negative consequences had
acceptable model fit (CFI = 0.90, TLI = 0.87, RMSEA = 0.051, SRMR=0.070).
Main findings of the analytic parallel process models (Study 1, Table 4)
Alcohol use frequency. Peer alcohol use was significantly correlated with the initial status
of alcohol use frequency (r=0.19, p<0.001). No other significant associations were present
between the predictors with the initial status and rate of change in alcohol use frequency.
Alcohol related negative consequences. The initial status of alcohol use frequency was
significantly and positively associated with the initial status of alcohol related negative
consequences (r=0.61, p=0.002). Similarly the increase in the slope of alcohol use frequency was
significantly, but weakly, related to the increase in the slope of alcohol related negative
44
consequences (r=0.06, p=0.04). No other associations were noted between the predictors of
interest and alcohol related negative consequences.
Invariance across gender. In order to determine whether these associations varied by
gender, an unconstrained model (with all paths free to vary across gender) was compared to a
constrained model (with each path constrained to be equal across gender) using the ΔCFI
(>.010), and the ΔRMSEA (>.010) criteria (Little, 2013). There was no significant difference in
fit between these two models for either outcome (Δχ
2
= 21.16, p = .164, ΔCFI = <0.01;
ΔRMSEA < .0.01) suggesting that these findings do not differ by gender of the participant.
Discussion
To the knowledge of the author, this study is the first to explore the role of cultural values
and traits in relation to alcohol use frequency and associated negative consequences in a
Hispanic sample. The goal of this analysis was to identify salient cultural values that could aid in
the identification of protective assets to prevent alcohol misuse among Hispanic emerging adults.
It was hypothesized that gender would moderate the relationships between cultural
factors and negative alcohol use consequences; however, following a test for invariance in the
measurement model it was determined that the final model did not vary by gender. However,
examination of the univariate growth models does show some interesting gender trajectories in
the cultural traits of interest that are worthy of discussion..
The similar decrease in familism scores may be the result of emerging adults spending
less time in their parents’ households or establishing their own independence as adults.
Participants’ detachment from the physical environment of a family household may decrease
feelings of dedication and loyalty to the family unit that is emphasized in Hispanic cultures.
Females may have experienced a less significant decrease than males over time as they are
expected to maintain stronger bonds with the family, continue family traditions and stay at home
45
longer than their male counterparts (Kopak et al., 2012). Males experienced a significant
decrease in respeto over time while the decrease in respeto for females was not statistically
significant. However, it is unclear why the change was only significant for males and not
females. One explanation is that males may not be expected to have the same devotion to their
parents and elders in the Hispanic culture and as they leave the family household to establish
themselves as adults leading their level of dedication to their parents, in particular, to decrease
over time.
While males did not experience any changes in fatalism over time, females reported a
significant increase in fatalism over time. Fatalism has been evidenced as a risk factor for not
engaging in positive health behaviors, such as breast cancer screening, among females (De Los
Monteros & Gallo, 2011), but this study suggests it may not be a risk factor for engaging in
harmful behaviors such as increased alcohol use or the experience of alcohol related negative
consequences. Of course, future work should examine this process specifically among females as
they did evidence a change in fatalism over time. Despite the null findings of the present study,
the role of fatalism should be considered as an important construct in alcohol use behavior as it
relates to other constructs associated with harmful alcohol use behavior, such as self-efficacy
(Ehret, Ghaidarov, & LaBrie, 2013; Maisto et al., 2015). For instance, individuals who attribute
their drinking outcomes to external forces may be less likely to take the necessary behavioral
actions to mitigate the likelihood of these outcomes occurring. Conversely, those who attribute
their alcohol-induced behaviors to their personal vulnerabilities may be more likely to engage in
protective behavioral strategies (e.g., watering down their drinks, arranging a designated driver,
etc.) to reduce the number of negative consequences they will experience. More research is
needed to disentangle these possible causal pathways.
46
None of the study hypotheses were supported, as there were no significant associations
between cultural values with alcohol use frequency or related negative consequences cross-
sectionally or longitudinally. However, this study does add to a growing literature that suggests
factors that predict alcohol use may not predict negative alcohol use consequences. Peer alcohol
use was significantly associated with the initial status of alcohol use frequency, but not with
alcohol related negative consequences, in this sample.
Previous work with this sample has not suggested that familism is a protective factor for
alcohol use in adolescence (Soto et al., 2009) or negative substance use consequences in
emerging adulthood (Grigsby et al., 2014). In Soto et al. (2009), higher familism levels served as
a risk factor for alcohol use among males contradicting the study’s hypotheses. Familism may
not serve as a protective factor as it reflects loyalty and dedication to the family, but does not
describe the values of the family unit. For example, someone with a high level of familism in a
family that approves or models alcohol use behaviors may be more harmful than beneficial
(Gloria & Peregoy, 1996; Soto et al., 2009) even if these behaviors are unintentional—such as
drinking at a family gathering or celebration. This explanation could extend to respeto as
individuals who respect their parents may be more likely to model negative behaviors, such as
alcohol use, leading to counterintuitive or null relationships with such health behaviors. These
idiosyncrasies should be reconciled in future work by collecting information on parental health
behaviors, family alcohol and drug use norms, and other contextual factors to determine when
and how familism or respeto can serve as protective—or possibly risk—factors for alcohol and
drug use.
Despite the lack of support for the hypotheses of this study, several results from this
analysis add to previous work on understanding negative alcohol use consequences in emerging
47
adult populations. Males had higher initial rates of alcohol use frequency and related negative
consequences relative to females, but females had a steeper increases in both alcohol use
frequency and negative consequences over time contradicting previous research (Grigsby et al.,
2016). Possible explanations for this finding is that males feel the need to drink more due to
social expectations (Wilsnack & Wilsnack, 2013) or due to differences in body size and
metabolism relative to females (Agarwal & Goedde, 2012). Regardless, this trend in the
literature underscores the need to reduce alcohol consumption among emerging adult males or to
introduce strategies to lower the harms associated with their alcohol use as negative
consequences increase over the young adulthood period—such as protective behavioral strategies
(Pearson, 2013).
Interestingly, after controlling for other variables in the model, peer alcohol use was not
significantly associated with the initial status or rate of change in alcohol related negative
consequences experienced by males or females in this study. Previous research has suggested
that peer alcohol use continues to exert influence on alcohol use behaviors into young adulthood
(see Stone et al., 2012). However, this discordant finding may be due to a significant proportion
of our sample not attending college, which has served as the setting for many of the positive
associations documented previously. Depressive symptomology was also not associated with the
initial status of either alcohol use outcome. The relationship between depression and alcohol or
drug use has been speculated as being bidirectional (Boden & Fergusson, 2011), and may
partially explain the lack of observed associations here. Specifically, individuals may be
experiencing negative alcohol use outcomes before experiencing depression. However more
work is needed to explore the possibility of concurrent mental illness and substance abuse
problems (Briers et al., 2014).
48
Limitations and conclusions
There are several important limitations to consider when interpreting these findings. First,
these findings may not be generalizable to all Hispanic residents in the United States, but may be
representative to young adults of Mexican American decent residing in urban areas similar to
Los Angeles. Second, we had a limited number of negative alcohol use consequences items in
the annual surveys. As a result, we may be underestimating the prevalence of problematic
alcohol use in this sample and the results of these analyses may be biased as a result. Third, we
observed attrition between the adolescent and emerging adulthood surveys and this may bias the
findings insofar as lower risk participants were more likely to be contacted. Finally, while
longitudinal analyses were performed, cause and effect statements should be made with caution
as these analyses are still correlational in nature.
The lack of statistically significant associations between the cultural values and negative
alcohol use consequences in the present study should not dissuade researchers from exploring
cultural risk and protective factors of substance use involvement. This analysis focused only on
the relevance of three specific cultural factors (familism, respeto, fatalism) and did not include
measures of other, possibly important, cultural traits and values salient among Hispanic groups.
For instance, gender differences in negative alcohol use consequences have been observed in
adolescent and young adult samples (Nolen-Hoeksema, 2004; Grigsby et al., 2016). Cultural
values such as machismo (described as positive and negative masculine traits such as dignity,
hard work, physical strength, male dominance) may encapsulate gender norm perceptions and
may be more important indicators of substance use involvement in Hispanic/Latino groups.
Earlier work with this sample demonstrated a positive association between machismo and
alcohol use among males—when a measure was included as part of the high school survey (Soto
49
et al., 2009). Exploring other cultural factors that pertain to problematic alcohol use could benefit
future prevention programs with Hispanic populations.
50
CHAPTER 4: PERCEIVED DISCRIMINATION PREDICTS NEGATIVE AND POSITIVE ALCOHOL USE
CONSEQUENCES, BUT NOT ALCOHOL USE FREQUENCY, AMONG HISPANIC EMERGING ADULTS
Background and Rationale
Hispanics experience a disproportionately higher rate of alcohol use problems than non-
Hispanic Whites despite reporting lower frequency of use and tend to outpace other racial ethnic
groups with the exception of Native Americans (Chen, Dufour & Yi, 2005; Chen, Yi &
Williams, 2009). As such, intervention programs to impede alcohol use escalation to problematic
or clinical levels of misuse are needed with this population. However, more work is needed to
clarify the motivation for continued alcohol use despite encounters with negative consequences
and to identify culturally relevant protective factors to develop an efficacious secondary
prevention program for Hispanic populations.
One possible avenue for understanding why individuals continue to use alcohol despite
experiencing negative consequences may be found in the experience of positive consequences.
Negative alcohol use consequences are the proximal and deleterious effects of alcohol use and
include neglecting responsibilities, getting into fights with loved ones or being unable to cut
down on use when desired. Conversely, positive alcohol use consequences reflect the short-term
benefits and positive outcomes of alcohol use and include increases in socialization and positive
physiological changes (e.g., relaxation). While positive consequences may be of less concern
from a public health perspective, it is important to consider the experience of rewarding events
that are attributed to drinking as they may assist in developing a coherent theoretical and
empirical model of the same behavior (alcohol use) that leads to eventual harm for the user or
their community.
Park (2004), for example, found that alcohol using participants reported positive
consequences more frequently and more intensely than negative consequences while Mallett,
51
Bachrach and Turrisi (2008) documented variation in the appraisal of specific alcohol
consequences as being negative or positive. Cognitive dissonance and unrealistic optimism
stemming from the experience of positive and negative consequences may encourage alcohol and
drug users to continue use despite the occurrence of harmful outcomes that result. Moreover, if
emotional reasons to drink exist (i.e., drinking to cope with depression or stress) then users may
not sufficiently weigh the pros and cons of alcohol use before the next alcohol use event or may
bias their perceptions to rationalize future alcohol use behavior to quell their emotional needs.
Also, previous research has documented that such predictors are typically more strongly
related to consequences than frequency or quantity of use and tend to differ for positive and
negative consequences (Park & Grant, 2005). The experience of positive and negative
consequences have been found to contribute to variation in future drinking behavior (Lee,
Maggs, Neighbors, & Patrick, 2011) and likelihood of rating future consequences as positive or
negative (Logan, Henry, Vaughn, Luk, & King, 2012), providing further evidence of the need to
examine both positive and negative consequences concurrently. Research on positive and
negative consequences of alcohol use has been limited to college samples and a focus on
psychological variables related to the use or misuse of alcohol.
Little work has examined positive and negative consequences concurrently, and more
work has focused instead on positive and negative expectancies of use. Expectancies reflect
expectations about using alcohol or drugs and may not always be in line with the outcome
(Dattilo, Murphy, Van Eck, & Flory, 2013; Dunne, Freelander, Coleman, & Katz, 2013;
Hatzenbuehler, Corbin, & Fromme, 2011) though they may influence the appraisal of specific
events that result from alcohol or drug use (Dunne et al., 2013). This study focuses on the
52
outcomes (consequences) of use without priming the participants to appraise the events as
positive or negative, but rather by whether they occurred or not.
Previous endeavors have also emphasized the role of intrapersonal and psychological
variables in predicting positive and negative consequences and have largely excluded
environmental and cultural factors. For instance, the role of cultural factors could be a relevant
factor in identifying problem users. Cultural influences are important to consider in health
behavior research as they impact the formation and maintenance of attitudes, beliefs and values
toward health behavior (Helman, 2007). Moreover, ethnic minority groups can experience stress
related to their group membership that majority groups do not experience.
Perceived discrimination, for example, is the experience of prejudice or unfairness due to
group membership and is more frequently reported by minority populations. Perceived
discrimination has been shown to have a harmful effect on mental and physical health outcomes
in ethnic minority groups (see Pascoe & Smart Richman, 2009 for review). Recent research has
produced mixed evidence showing that stronger affiliation with one’s heritage group, described
as cultural or ethnic identity, may serve as a source of resilience and function as a protective
factor against substance use for different minority groups (Iwamoto, Takamatsu, & Castellanos,
2012; Stevens-Walkins, Perry, Harp & Oser, 2012) or lead to an increased risk of substance use
(Wong & Longshore, 2008; Zamboanga, Schwartz, Jarvis, & Van Tyne, 2009).
However, to date, no research has examined if ethnic identity buffers the adverse effects
of perceived discrimination on alcohol use outcomes. This research question is of interest as
attachment to cultural values believed to be protective against substance use (e.g., the Hispanic
paradox) could offset the negative influence of sociocultural stressors, such as perceived
discrimination. The present investigation aims to partially fill the gap in the existing literature by
53
exploring the role of cultural risk and protective factors for a community sample of Hispanic
emerging adults reporting alcohol use where alcohol use consequences are the outcome. This
research can benefit prevention scientists by aiding in the development of culturally tailored
alcohol misuse interventions.
Current study
The purpose of the present investigation is to examine the relationship between perceived
discrimination with alcohol use consequences (positive and negative) with frequency of use as a
mediator. A secondary goal is to establish whether cultural identity moderates these
hypothesized relationships. This analysis will add to a growing body of literature on the
relationship of specific cultural factors related to substance use and misuse in Hispanic
populations and will inform future interventions with this population. It is hypothesized that:
(1) Perceived discrimination will be positively associated with both positive and negative
consequences of alcohol,
(2) Alcohol use frequency will mediate the relationship between perceived discrimination
and alcohol use consequences, and
(3) Ethnic identity will moderate the relationship between perceived discrimination and
negative alcohol use consequences where increases in cultural identity will reduce the
strength of the association between perceived discrimination and negative or positive
consequences. It is hypothesized that a similar moderated relationship will be
observed between perceived discrimination and alcohol use frequency.
Ethnic identity is a construct that assesses the connection to one’s ethnic group and
values, but does not necessarily represent the practice of cultural values. Moreover, the goal of
the investigation is to understand how this connection to one’s ethnic group and values may
54
offset the experience of sociocultural stress, such as experiencing perceived discrimination. Due
to multicolinearity issues and the null effects observed in study one, the present analysis did not
control for familism, respeto, and fatalism.
Analysis Plan
A moderated mediation model was utilized to test the research question as to whether
cultural identity modifies the effect of perceived discrimination with positive and negative
alcohol use consequences where alcohol use frequency serves as a mediator (Muller, Judd, &
Yzerbot, 2005). Preliminary path analysis models were used to determine the conditional indirect
effects of perceived discrimination on positive and negative alcohol consequences for this
sample of Hispanic emerging adults. A conditional indirect effect is defined here as the
magnitude of an indirect effect at a particular value of the moderator (cultural identity). To
explore possible moderation effects by cultural identity, two interaction terms were created for
each model (cultural identity x perceived discrimination and cultural identity x alcohol use) to
explore if, and to what extent, cultural identity serves as a buffer the relationship between
perceived discrimination with alcohol use and related consequences (see figure 4 for illustration).
As no evidence of statistical mediation was present (see Results below), direct effects
analyses (without the presence of a mediator) were carried out. However, upon examining the
distribution of residuals in the outcome variables and unsuccessful transformations to correct the
violation, final analyses were carried out using a negative binomial regression with the NBREG
command in Stata version 14. To use the NBREG command, the quantity of alcohol related
negative consequences (range: 0-7) and positive consequences (range: 0-15) were used as the
outcome. The negative binomial regression model was chosen due to the Poisson-like
distribution of the nonnegative count outcome variables that account for overdispersion.
Adjusted incidence-rate ratios (IRR) and 95% confidence intervals (95% CI) are presented.
55
Results
Sample statistics
A total of 999 participants provided data on the variables of interest at EA waves 3 and 4.
Participants with no data on alcohol use, or whom reported no alcohol use, at wave 4 were
excluded from the analysis (n=290). Of the remaining 709 participants, approximately 41%
(n=295) were male. Study 2 Table 1 provides descriptive statistics for the variables of interest in
this analysis. Of note, participants recalled more positive than negative alcohol use consequences
in the past thirty days.
Mediation analyses
Mediation analyses were performed to assess whether frequency of alcohol use mediates
the relationship between perceived discrimination and alcohol use problems. Unadjusted models,
without covariates, did not evidence any statistically significant relationships among the
predictor (perceived discrimination), mediator (alcohol use frequency) and outcomes (positive
and negative alcohol use consequences) of interest. Specifically, the path from perceived
discrimination to alcohol use frequency (path a) was non-significant (p>0.05) while the path to
alcohol related negative and positive consequences (path b) were significant (p’s <0.05). In
addition, after adjusting for gender, depression (CES-D score), and peer alcohol use a similar
pattern of associations were noted. As such, only direct effects analyses were performed in the
final analysis. Since hypotheses regarding mediation were not supported the final analyses only
explored the hypothesized moderation effects.
To explore the possibility that alcohol users were experiencing negative consequences for
reasons other than consuming too much alcohol, threshold effects were explored. First, adopting
a strategy proposed by Read and colleagues (year), global differences were explored in alcohol
use problems as a function of drinking intensity—operationalized by quartile of alcohol use
56
frequency. Results of a one-way ANOVA revealed significant differences in negative alcohol
use consequences between alcohol use frequency quartiles (F=81.30, p<0.0001). A post-hoc
Scheffe test revealed significant mean differences between the highest quartile and lower
quartiles (p’s <0.001), but no significant difference between individuals in the first and second
quartiles (p>0.05). Similarly, the one-way ANOVA results showed significant global
differences in positive consequences by quartile of alcohol use frequency (F=70.89, p<0.0001).
The Scheffe test revealed significant mean differences between all pairs of quartiles of alcohol
use frequency (p’s <0.001) with individuals in the higher quartiles of alcohol use frequency
reporting significantly more positive consequences than individuals in lower quartiles.
Locally weighted smoothing (lowess) plots were constructed to explore the data and
evaluate the best fit to describe the relationship between alcohol use frequency with positive and
negative alcohol use consequences and to visually observe possible thresholds in drinking
behavior that produce consequences. Lowess smoothing plots revealed a linear relationship
between alcohol use frequency with negative (Study 2, figure 1a) and positive consequences
(Study 2, figure 1b). In both cases, it appears—from visual inspection—that alcohol use
consequences increase as a function of increased alcohol use. Of note, individuals reporting the
lowest level of alcohol use (1-2 drinks in the past 30 days) were reporting, on average, four
positive consequences from alcohol and no negative consequences. While these plots support the
findings of the ANOVA tests—suggesting that alcohol use consequences are, at least partially,
explained by the frequency of alcohol being used—there do appear to be some differences in the
relation between alcohol use with positive and negative drinking outcomes.
Direct effects findings
57
Separate negative binomial regression models were performed to explore prospective
relationships between perceived discrimination with positive and negative alcohol use
consequences controlling for gender, alcohol use frequency, ethnic identity, depression and peer
alcohol use (Study 2 - Table 2).
Negative alcohol use consequences. Controlling for covariates, perceived discrimination
was positively and prospectively associated with experiencing more negative alcohol use
consequences (IRR=1.02, 95% CI=1.01, 1.04). More negative alcohol use consequences were
reported by males than females (IRR=1.21, 95% CI=1.00, 1.47), and were experienced more as a
function of alcohol use frequency (IRR=1.66, 95% CI=1.54, 1.80), depressive symptomology
(IRR=1.03, 95% CI=1.01, 1.04) and having more close friends that used alcohol (IRR=1.20,
95% CI=1.05, 1.38). Ethnic identity was not associated with experiencing negative alcohol use
consequences. Moreover, ethnic identity did not moderate the effect of perceived discrimination
on the number of negative alcohol use consequences reported by alcohol users (p>0.05).
Positive alcohol use consequences. Controlling for covariates, perceived discrimination
was positively but marginally associated with the likelihood of experiencing more positive
alcohol use consequences (IRR=1.01, 95% CI=1.00, 1.02). Positive associations were also
present for ethnic identity (IRR=1.18, 95% CI=1.08, 1.36) and alcohol use frequency (IRR=1.33,
95% CI=1.27, 1.41). Males, relative to females, reported experiencing more positive
consequences from alcohol use (IRR=1.15, 95% CI=1.01, 1.30). Finally, experiencing more
positive consequences from alcohol use was higher for individuals with more alcohol using close
friends (IRR=1.28, 95% CI=1.18, 1.40) but not with higher depressive symptomology scores.
There was no evidence that ethnic identity moderated the relationship between perceived
discrimination and positive alcohol use consequences (p>0.05).
58
Reverse association. To examine the temporal relationship between perceived
discrimination and negative alcohol use consequences, a multivariate linear regression model
was performed with negative consequences at EA wave 3 as a predictor and perceived
discrimination at EA wave 4 as the outcome while controlling for the same covariates. Results
indicate that experiencing negative alcohol use consequences at wave 3 is positively and
significantly associated with level of perceived discrimination at wave 4 (β=0.09, p=0.029), but
is not significantly associated with a change in discrimination between waves 3 and 4 (β=0.23,
p=0.065). Unfortunately, positive alcohol use consequence items were not entered into the
survey until the final assessment (EA wave 4) so we cannot exclude the possibility of reverse
causation (temporal ordering).
Discussion
This study is the first to explore the prospective relationships between perceived
discrimination and alcohol use consequences in a Hispanic sample while controlling for
psychological and social factors, a limitation of previous work with Hispanic samples (Cheng &
Mallinckrodt, 2015). In addition, this study also contributes to the scientific literature by
exploring how these relationships differ when examining positive and negative consequences of
alcohol use. Hispanic young adults reported more positive than negative alcohol use
consequences. Finally, this work supports previous research suggesting that having peers who
use alcohol and psychological distress contribute to proximal, adverse alcohol use outcomes
(Leung, Toumbourou, & Hemphill, 2014; Stone et al., 2012; Snyder & Rubenstein, 2014).
Unfortunately, the majority of the study hypotheses were not supported, as there was a
lack of a mediational relationship between perceived discrimination, alcohol use frequency and
positive or negative alcohol use consequences. In particular, there were no direct associations
between perceived discrimination and alcohol use frequency between these two assessments
59
after controlling for other relevant factors. Previous work with this sample also suggests that a
longitudinal relationship between perceived discrimination and alcohol use is nonexistent (Unger
et al., 2014). This is interesting given that final statistical models did show evidence of
prospective relationships between perceived discrimination with negative and positive alcohol
use consequences when controlling for alcohol use frequency.
Perceived discrimination may lead to changes in alcohol induced behaviors, but not
alcohol use itself, due to underlying variables that mediate the relationship between
discrimination and behavior. For instance, individuals experiencing discrimination may
experience higher levels of disinhibition when under the influence of alcohol causing them to act
differently than they normally would thereby producing positive and negative outcomes
accordingly. Likewise, this relationship may be due to an unknown factor that moderates the
relationship between alcohol use and related consequences among individuals experiencing
discrimination. For example, people experiencing discrimination may turn to alcohol as a means
of coping or social enhancement and their motives for alcohol use may impact how they behave
when under the influence of alcohol. In order to sufficiently explain how discrimination relates
to alcohol related behaviors, but not alcohol use itself, it is imperative for scientists to explore
possible underlying factors that mediate or moderate the relationship observed here.
This is not the first instance where variables have been found to be predictive of negative
alcohol use consequences, but not alcohol use. However, this is the first study to document a
positive association between perceived discrimination with negative and positive alcohol use
consequences. Of note, the relationship between perceived discrimination and negative
consequences might be bidirectional as follow-up analyses did indicate that earlier alcohol
related negative consequences predict later levels of perceived discrimination. Individuals
60
experiencing problems with alcohol may have a heightened threat appraisal and vigilance of day-
to-day situations or may be engaging in behaviors that garner disapproval from others but
misattribute it to their ethnicity rather than their drinking behaviors. For those from ethnic
minority backgrounds, these threats may be partially attributed to their cultural background. This
may explain the reverse association observed in the present analysis.
Perceived discrimination was also prospectively associated with positive alcohol use
consequences. While we cannot rule out the possibility of reverse causation, this finding suggests
that alcohol use may temporarily ease the burden of feeling discriminated against and lead to
feelings of fitting in or having an easier time navigating social situations (i.e., positive
consequences). However, these positive outcomes may feed future alcohol expectancies and
motivate individuals to continue drinking at a problematic level that leads to unfavorable
outcomes such as blacking out or missing school and work (Park, 2004; Lee et al., 2011). This
may also partially explain the reverse association between perceived discrimination and negative
alcohol use consequences. In particular, those drinking to ease discrimination related stress may
experience more problems due to their alcohol use. There is also a possibility that this continuum
of behavior leads to social exclusion or microaggressions they attribute to their ethnic
background instead of their drinking habits. More work is needed to detect such patterns that
would explain this relationship in order to improve our understanding of the complex
interrelationships between environmental stress, alcohol use and resulting positive and negative
consequences.
The minority stress theory (Meyer, Schwartz, & Frost, 2008), a derivative of the larger
stress-coping theories (Lazarus, 1993), posits that being a member of a minority or ethnic group
increases the likelihood of experiencing discrimination and other similar types of stress.
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Assuming this theory is valid, individuals from ethnic minority backgrounds should be
considered an at-risk population considering that discrimination has been shown to lead to
numerous adverse health outcomes (Pascoe & Smart Richman, 2009). Based on the results of
this study, it is recommended that researchers identify targets for intervention to offset the effects
of perceived discrimination on alcohol misuse. There are several avenues worthy of exploration
in this regard. For example, Hispanic youth may benefit from racial socialization (Hughes, 2006)
where they learn adaptive strategies to cope with discrimination and accept discrimination as a
part of life for ethnic minority groups. Racial socialization occurs in most ethnic minority groups
to some extent (Hughes, 2006), but varies in intensity and content or delivery of messaging.
We also did not observe any statistically significant moderation effects, discounting
hypotheses that ethnic identity may buffer the negative effects of perceived discrimination on
positive and negative alcohol use consequences. The lack of a buffering effect may be explained
by the direct relationships observed between ethnic identity and alcohol related consequences.
Interestingly, ethnic identity was not statistically associated with negative alcohol use
consequences, but was positively associated with positive alcohol use consequences. Previous
research has documented a mixed relationship between ethnic identity and alcohol involvement
(Zamboanga et al., 2009), and researchers have discussed some ecological and methodological
possibilities for these unexpected and inconsistent relationships as outlined below.
First, ethnic identity may not serve as a protective factor from alcohol involvement in
contexts where minority groups are the numerical majority. In such environments, perceptions of
social standing relative to other groups may be higher and identification with a dominant group
may serve as a risk factor or positive indicator of socially acceptable behaviors despite associated
adverse outcomes, such as negative alcohol use consequences. Second, from a methodological
62
standpoint, the statistical model may not have detected the underlying mechanisms that may
explain this relationship. For instance, previous work has suggested that ethnic identity is
positively associated with heavier drinking among college males, but not females (Zamboanga,
Raffaelli, & Horton, 2006) though gender did not moderate the observed relationships in the
present investigation. Future work should replicate this finding and attempt to address these
limitations more efficiently by collecting additional data and building more dynamic, complex
statistical models to explain this relationship.
Participants recalled a greater proportion of positive, relative to negative, alcohol use
consequences and there are several possible explanations for this finding. First, participants may
be subject to “euphoric recall”—an implicit cognitive bias to remember positive events and
overlook negative ones. This could be especially problematic if drinking takes place in social
situations where others can reinforce and highlight the positive outcomes while simultaneously
separating and ignoring the negative ones (Smith & Berger, 2010). Second, on a related note,
larger implicit cognition processes may drive these results. Researchers have emphasized the role
of alcohol use expectancies as a possible unifying construct for explaining alcohol use cognitions
(Goldman, Reich, & Darkes, 2006) that may drive recall of alcohol-related events, and have
recommended the need for implicit cognition tests in alcohol use research (Fadardi, Cox, &
Klinger, 2006). The present study supports this position especially in cases where positive and
negative alcohol use consequences are being examined concurrently. Additionally, it is
recommended that corroborative evidence (e.g., naturalistic observation) be utilized to examine
discrepancies in the recall of positive and negative alcohol use consequences at specific drinking
occasions. Finally, participants may actually experience more positive than negative outcomes
63
from their alcohol use and may use this discrepancy to justify future alcohol use despite possible
increases in negative consequences.
Limitations and conclusions
There are several important limitations to this analysis that are noteworthy. First, these
results can only be generalized to Mexican-American young adults residing in urban areas
similar to Los Angeles, California. Second, while the associations in this study were prospective
there is still temporal ambiguity in the ordering of events. As such, these findings should be
interpreted with caution. Third, while this study controlled for empirically established predictors
of negative alcohol use consequences, we did not include others such as alcohol use motives and
expectancies. Fourth, threshold effects were explored to rule out the possibility that individuals
reporting positive or negative consequences from alcohol were not the result of drinking too
much alcohol. Unfortunately, the Project RED study does not have event level data and relied on
past 30-day estimates of alcohol use and related consequences to explore thresholds. As such,
while it appears that a linear relationship exists between alcohol use frequency and alcohol use
problems, it is likely that this relationship doesn’t persist when examining specific occurrences
of drinking and associated problems. Finally, these findings cannot be generalized to positive
and negative outcomes that are experienced through the use of other licit or illicit substances.
The results of the study support previous calls to address both positive and negative
consequences from drinking (Park, 2004; Lee et al., 2011). The present findings indicate that
there are more similarities than differences in the relationship between cultural, psychological
and social predictors of positive and negative alcohol use consequences. This suggests that
research into alcohol use and misuse may be overlooking important contributing factors for
Hispanic emerging adults, such as perceived discrimination and other cultural stressors, in the
64
process from alcohol use to misuse and later abuse or dependence. Young adults from ethnic
minority backgrounds may use alcohol as a means of coping with stress and using to the extent
that it engenders immediate deleterious outcomes. This pattern should be interrupted to reduce
the risk of Hispanic young adults from escalating to addiction, abuse or dependence by
developing prevention curricula to undermine the negative effects of discrimination by
improving healthy coping strategies, self-perception and refusal self-efficacy skills. Future
research should focus efforts on understanding the complex relationship among social
experiences, alcohol use and continued alcohol use in the face of the negative consequences that
can result.
65
CHAPTER 5: QUANTITY OF ALCOHOL USE PROBLEMS MODIFIES THE EFFECT OF PERCEIVED
DISCRIMINATION ON PHYSICAL INTIMATE PARTNER VIOLENCE PERPETRATION FOR HISPANIC
EMERGING ADULTS
Background and rationale
Intimate partner violence (IPV) is any form of physical, emotional or verbal aggression
used against a current, or past, romantic partner of any gender or relationship status (Centers for
Disease Control and Prevention (CDC), 2008). Data from nationally representative samples
indicate that approximately 24% of women and 14% of men in the United States (U.S.) have
experienced some form of IPV in their lifetimes (CDC, 2010). Of course, population-based
estimates may be conservative, and not accurately portray the extent of the problem in subsets of
the U.S. population. For instance, studies using college student and community-based samples
report higher prevalence rates varying between 30% and 50% (Archer, 2006; Coker et al., 2002;
Reid et al., 2008) suggesting that IPV may be an overlooked but more serious public health
problem than previously considered.
Aside from the immediate physical and psychological trauma that results from
experiencing physical, verbal, or sexual abuse, victims of IPV are more likely to experience
chronic health problems, involvement with law enforcement and child welfare agencies,
depression, HIV infection, and premature death (Campbell, 2002; Coker et al., 2002; El-Bassel et
al., 2003; Gilbert, El-Bassel, Schilling, Wada, & Bennet, 2000). The impact of IPV can carry
over to children of victims and heighten the risk of delinquent behavior, impaired social
functioning and dysfunctional romantic relationships in adulthood (Spanvill, Clayton, Hendrix,
& Hunsaker, 2007; Black, Sussman, & Unger, 2010; Silverman, Raj, Mucci, & Hathaway,
2001). This evidence warrants more work to investigate subgroups of the U.S. population at
heightened risk for IPV and empirical investigations of meaningful risk and protective factors
that can be targeted in intervention settings.
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To date, research has documented higher rates of IPV in minority groups relative to non-
Hispanic White counterparts although the exact discrepancy has not been determined (for
review, see Field & Caetano, 2004), and there is a growing body of evidence suggesting that
emerging adulthood (ages 18-25) is a developmental period when risk of experiencing violence
in a romantic relationship is highest (Breiding, Black, & Ryan, 2006; Halpern, Spriggs, Martin,
& Kupper, 2009).
Known factors contributing to IPV victimization and perpetration
IPV is a complex behavioral phenomenon, and it has been argued that numerous
characteristics contribute to perpetration, victimization and reciprocity of violence in romantic
settings. Early investigations argued IPV was a form of gender based power and dominance
(Straus, Gelles, & Steinmetz, 1980), but was later explained as a behavior that was learned from
one’s environment (i.e., social learning theory; Kalmuss, 1984; O’Leary, 1988). More recently,
however, research has focused on important intraindividual characteristics (e.g., personality
traits) and the possibility of genetic predisposition to violent behavior (Dutton, 1995;
Holtzworth-Munroe & Stuart, 1994; DeWall & Way, 2014). The aggregate of this work has led
researchers to adopt a developmental framework (see Ehrensaft, 2008) to explore the numerous
intrapersonal, micro and macro social antecedents of IPV through the lifespan and in the process,
two robust risk factors have been identified: experiencing abuse in childhood and alcohol
involvement.
Adverse childhood events (ACEs) are retrospective survey measures that collect
information on childhood verbal, physical and sexual abuse in the household. Childhood
maltreatment and exposure to parental IPV have been linked to aggressive behaviors in
adolescents (Dodge et al., 1990; Holt, Buckley, & Whelan, 2008; Margolin, 2005) and more
67
recently to IPV in adults (Black, Sussman, & Unger, 2010; Ehrensaft et al., 2003; Renner &
Slack, 2006; Roberts et al., 2011). Trauma based theories argue that childhood victimization can
lead to engagement in several deviant activities as coping mechanisms for the severe stress
experienced earlier in life including, but not limited to: substance use, aggression, delinquency,
and violence (Dube et al., 2006; Duke, Pettingell, McMorris, & Borowsky, 2010). Researchers
have postulated that exposure to childhood maltreatment may increase perceived need for self-
protection (Lewis, Leeb, Kotch, Smith, & Thompson, 2007), feelings of hopelessness and
depression (Bergen, Martin, Richardson, Allison, & Roeger, 2003) or perceptions that abusive
relationships are normative leading to a rationalization that IPV is a normal and acceptable part
of a romantic relationship. Therefore, childhood victimization is an important covariate to
consider when evaluating the theoretical relationship between sociocultural stress, alcohol
involvement and IPV involvement.
Theoretical and empirical evidence of alcohol and IPV exposure relationship
Alcohol use has been implicated as an important risk factor for IPV as results from a
recent meta-analysis (Foran & O’Leary, 2008a) suggests that alcohol explains approximately
23% of the variance in male to female IPV (95% CI = 21% - 24%) and 14% of the variance in
female to male IPV (95% CI = 8% - 20%). The alcohol-IPV association may be explained by
alcohol’s ability to lower inhibitions and decrease ability to successfully interpret social cues,
and may even be a consequence of alcohol misuse. However, theoretical models are in
disagreement as to the nature of the relationship between the two. Debates in the literature
suggest that there are three possible explanations for the alcohol-IPV link (Leonard & Quigley,
1999; Foran & O’Leary, 2008a).
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First, the spurious effects model suggests that observable associations are due to other
factors that co-vary with alcohol and IPV such as young age and antisocial personality or
confounders such as underlying genetic influences. However, studies that have controlled for
possible confounders have found the relationship persists (Caetano, Vaeth, & Ramisetty-Mikler,
S., 2008; Cunradi, Ames, & Moore, 2008; Cunradi, 2009) although the strength and direction of
relationships vary by gender and whether IPV perpetration or victimization is being assessed.
The indirect effects model posits that the alcohol-IPV link is mediated by contextual and
relationship factors such as marital dissatisfaction. Again, when controlling for such factors as
mediators, the direct association remains (Sullivan, Ashare, Jaquier, & Tennen, 2012). Finally,
the proximal effects model, suggests alcohol is directly related to IPV. The present investigation
is driven by the latter theoretical perspective as empirical results have consistently demonstrated
that IPV was higher on drinking days versus non-drinking days in several samples (Fals-Stewart,
Golden, & Schumacher, 2003; Fals-Stewart, Leondard, & Birchler, 2005; Schumacher, Coffey,
Leonard, O'Jile, & Landy, 2013) and other studies have provided little to no evidence to support
other explanatory models.
Problem alcohol use and IPV
There is additional evidence that the strength of the relationship between alcohol
involvement and IPV may be greater in clinical samples or when individuals with more severe
forms of alcohol use (e.g., alcohol abuse/dependence) are investigated. Problem alcohol use, the
experience of proximal and deleterious effects from drinking, may also serve an important role
unique from typical measures of alcohol frequency or quantity. Problem alcohol use can be
construed as a form of alcohol misuse as people who continue to use alcohol despite immediate
negative consequences may differ from the typical alcohol user. For instance, they may have
69
higher levels of impulsivity thereby reducing their ability to assess short- and long-term
consequences of their actions or their alcohol use may be one of several externalizing behaviors
used to cope with exposure to acute and/or chronic stress. This may explain its unique
relationship with IPV. For instance, Cunradi, Caetano, & Schafer (2002) found that alcohol
problems, for both genders, were significantly related to moderate and severe IPV. This finding
has been rather consistent in other studies (Foran & O’Leary, 2008b; Cunradi, Todd, Duke, &
Ames, 2009), but two important limitations of most previous work should be noted. First,
researchers have focused primarily on male to female violence, and second, there has been less
work examining perpetration and victimization concurrently. The present study addresses these
issues by examining IPV perpetration and victimization experienced by both genders in a
community based sample of Hispanic emerging adults.
Exploring the role of sociocultural stressors in IPV
For Hispanic samples, targeting specific sociocultural stressors associated with negative
health behaviors may be a worthwhile pursuit. While acculturation, broadly defined as the
process of adapting to a host culture, has gained considerable attention in relation to IPV in
recent years, the results have been mixed. Some studies have reported that being more
acculturated to American society or experiencing higher levels of acculturative stress is
associated with an increase in IPV among Hispanics (Lown & Vega, 2001; Caetano et al., 2007)
while others have not observed a relationship between acculturation factors and IPV (Cunradi,
2009). This discrepancy reflects the complex and multidimensional nature of acculturation and
underscores the need for research targeting specific sociocultural variables. One promising factor
that can aid in disentangling this phenomenon is perceived discrimination.
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Perceived discrimination can be described as a sociocultural stressor where individuals
of a group are treated differently due to their group membership. Smokowski and Bacallao
(2006) documented higher rates of aggressive behavior among youth reporting higher levels of
perceived discrimination. Perceived discrimination has also been shown to be a risk factor for
dating violence victimization in female Hispanic youth (Sanderson et al., 2004), and other work
has suggested it may lead to poor mental health outcomes as well (Paradies, 2006; Williams &
Mohammed, 2009). More recently, Forster and colleagues (under review) examined the link
between perceived discrimination and IPV victimization in this sample of Hispanic emerging
adults and found that it was the strongest predictor of verbal and physical IPV victimization after
controlling for gender, adverse childhood events, socioeconomic status, education and other
cultural variables. Perceived discrimination may heighten acculturative stress and may
undermine personal and social support mechanisms. Alternatively, experiencing discrimination
may be an indicator of personal vulnerability and this could lead to an increase in the incidence
of violence exposure.
Perceived discrimination may also serve an important role in substance use behavior.
Research with U.S.-born Hispanic youth, specifically, has suggested that perceived
discrimination is positively and prospectively associated with substance use attitudes and
behaviors (Kulis, Marsiglia, & Nieri, 2009; Okamoto et al., 2009; Tran, Lee, & Burgess, 2010).
Alcohol and drug use may serve as a coping mechanism to handle increased levels of stress
resulting from discrimination, and may lead to rapid escalation resulting in problem use. The
goal of the present investigation is to explore whether problem alcohol use modifies the
relationship between perceived discrimination and IPV perpetration and victimization in an
emerging adult Hispanic sample of alcohol users.
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Current study
The theoretical support that perceived discrimination and problem alcohol use may serve
as important proximal predictors of IPV perpetration or victimization has warranted the present
empirical investigation. The objective of the present analysis is to assess the possibility of effect
modification of alcohol problem use on perceived discrimination and investigate how this
relationship predicts IPV perpetration and victimization. After controlling for theoretically
meaningful covariates (depressive symptomology, peer alcohol use, ACEs, gender), it is
hypothesized that (a) perceived discrimination and alcohol use problems will have independent
positive associations with IPV perpetration and victimization and (b) the odds of IPV
perpetration and victimization will increase as a function of the multiplicative effect of perceived
discrimination and alcohol use problems. No specific hypotheses are made by IPV type (e.g.,
psychological, physical or sexual). Finally, gender differences will be explored as alcohol use
problems and IPV victimization and perpetration appear to differ for males and females (Foran &
O’Leary, 2008a), but no a priori hypotheses are made regarding the direction or strength of these
relationships.
The goal of this investigation is to extend previous work with this sample (Forster et al.,
under review; Forster et al., in preparation) by exploring if and how alcohol use problems modify
the association between perceived discrimination and IPV victimization and perpetration among
Hispanic emerging adults who use alcohol.
Analysis plan
Descriptive statistics were calculated for all variables of interest and examined separately
for males and females. Multivariate logistic regression models were used to examine the
influence of perceived discrimination, problem alcohol use, ACEs, and gender in predicting
victimization and perpetration of each IPV type (psychological, physical and sexual) while
72
controlling for peer alcohol use and depressive symptomology. To capture moderation effects of
problem alcohol use on perceived discrimination, multiplying the scores for perceived
discrimination and number of alcohol related negative consequences experienced in the past 30
days created an interaction term. A three-way interaction term was used to explore possible
gender differences (gender*alcohol problems*perceived discrimination). All analyses were
performed in Stata version 12 (Stata Corp, 2011).
Results
Descriptive statistics
The Project RED sample was limited to individuals who reported past 30-day alcohol use
during EA wave 2 (n=1,004) to create the analytical sample for the present study. Study 3 –
Table 1 displays descriptive statistics for the analytic sample in addition to gender differences for
the variables of interest in the study. Of the 1,004 participants in the analytic sample, 59.8%
(n=600) were female. Males and females significantly differed in quantity of alcohol problems
(p<0.01) and level of perceived discrimination (p<0.05) with males indicating significantly
higher scores on both variables. Males and females did not significantly differ in experience of
ACEs or IPV victimization. However, there was a discrepancy in IPV perpetration with a higher
proportion of females than males reporting psychological (p<0.001) and physical (p<0.01)
violence. Males, however, were more likely to report sexual IPV perpetration (p<0.001).
Main findings
IPV Victimization. Quantity of alcohol use problems was positively and significantly
associated with physical IPV victimization (OR=1.20, 95% CI = 1.04, 1.39). However, alcohol
use problems were not significantly related to any other form of IPV victimization and there
were no significant relationships between perceived discrimination and any type of IPV
victimization (Study 3 – Table 2).
73
IPV Perpetration. Alcohol use problems and perceived discrimination were not
associated with verbal or sexual IPV perpetration (Study 3 – Table 3). For physical IPV
perpetration, significant direct effects and statistical interactions were observed. In the statistical
model including the 2-way interaction term (alcohol use problems*perceived discrimination) the
simple effect (the effect of one predictor within one level of a second predictor) of alcohol use
problems suggests that for each additional alcohol use problem, the odds of perpetrating physical
IPV increased by 27% (OR=1.27, 95% CI = 1.08, 1.49). The simple effect of perceived
discrimination on physical IPV perpetration showed as similar positive association as the odds of
IPV perpetration increased by 3% for every unit change in perceived discrimination (OR=1.03,
95% CI=1.01, 1.07). There was a significant interaction between alcohol use problems and
perceived discrimination (OR=0.98, 95% CI=0.97, 0.99) suggesting that the average effect of
perceived discrimination dampens as alcohol use problems increase. As shown in Study 3 -
Figure 1, the average effect of perceived discrimination on IPV perpetration was only
significantly lower for individuals who reported experiencing all seven negative alcohol use
consequences listed on the survey. None of the findings varied significantly by gender according
to three-way interaction terms entered into the statistical models (p>0.05).
Discussion
This study investigated the combined influence of alcohol use involvement and
sociocultural factors in predicting IPV victimization and perpetration. More than half of the
analytic sample reported some form of IPV, consistent with previous prevalence estimates and
community based research with young adult samples (Archer, 2006; Coker et al., 2002; Reid et
al., 2008). Among those reporting alcohol use, females were also observed as having higher odds
of reporting psychological and physical IPV and no significantly different chances of reporting
74
IPV victimization relative to males, supporting recent evidence that suggests IPV perpetration is
not a phenomena exclusive to males (Foran & O’Leary, 2008a).
Consistent with the first hypothesis, there was a direct association between perceived
discrimination and alcohol use problems with physical IPV perpetration. This finding bolsters
and extends earlier results with this sample (Forster et al., in preparation). Perceived
discrimination might hinder an individual’s ability to seek external resources and learn to address
relationship issues in a positive manner. This may be due to fear of stigmatization (Vogel, Wade,
& Hackler, 2007) that could also partially explain lower levels of mental health care among
Hispanics, in general (Gary, 2005). Additionally, perceived discrimination may enhance
behavioral patterns while under the influence of alcohol (see Study 2 results and discussions), a
risk factor that has been established as an important covariate of IPV involvement. This supports
previous research (see Duke, Giancola, Morris, Holt, & Gunn, 2011) that implicates alcohol as a
causal mechanism for aggressive and violent behaviors due to its neurobiological effects
resulting in behavioral disinhibition and an increase in threat perception. Similarly, alcohol
depresses the nervous system and may lead to slower reaction times making it difficult to
perceive or react to physical violence.
However, we did not observe any other direct relationships for psychological or sexual
IPV perpetration or victimization. We also did not observe the same relationship between
perceived discrimination and IPV victimization as reported by Forster and colleagues (under
review), but this is likely due to the restriction of the current analytic sample to alcohol users and
the use of different covariates in the statistical analysis. The specificity of the relationships
observed here suggests that problem alcohol use among drinkers may make individuals more
susceptible to physical aggression in romantic settings. Quantity of alcohol use problems was
75
also associated with physical IPV victimization. This is not surprising given that alcohol
depresses the nervous system making it difficult to perceive social cues and react to physical
violence. Individuals seeking treatment for physical IPV involvement should be screened for
alcohol use and related problems and subsequently treated as a means of improving IPV
outcomes.
There was partial support for the second hypothesis that alcohol use problems would
modify the effect of perceived discrimination on IPV victimization and perpetration. Similar to
the direct associations observed in this study, there was only evidence of effect modification
when predicting physical IPV perpetration. Notably, the direction of the interaction was not
expected as alcohol use problems did not enhance the effect of perceived discrimination, but
dampened it. There are several possible explanations for this observation.
First, individuals reporting the highest level of alcohol use problems (endorsing that they
experienced all seven negative consequences on the survey) may be experiencing such high
levels of alcohol use and negative consequences that they are experiencing an alcohol use
disorder. Such individuals may experience higher rates of failed relationships due to negligence
of their partner’s needs and little attention to any personal relationships, in general. Second, it is
possible that individuals experiencing the highest level of alcohol use problems may be
hypersensitive to perceived discrimination and may alter their behaviors, such as perpetrating
physical IPV, or their survey responses as a result. This is particularly concerning as such
individuals may be less likely to seek treatment and more likely to substitute other negative
behaviors that could be more harmful to themselves or others. Finally, there is a possibility that
this relationship was spurious and occurred by chance. The dampening effect of perceived
discrimination on physical IPV perpetration only occurred at the highest level of alcohol use
76
problems that was reported by less than 8% of the sample. Replication of these findings is
warranted before they can be established as statistically or clinically relevant.
Limitations and conclusions
There are several limitations to this study that are worth noting. First, the sample was
constituted of primarily Mexican-American emerging adults residing in Los Angeles, California
and the results may not generalize to other groups until the results have been replicated. Second,
alcohol use problems were assessed as using a composite index to capture the quantity of
negative consequences reported by participants on the EA wave 2 survey. This measurement
strategy may provide an estimate of problem use severity as opposed to intensity and the results
should be interpreted as such. Third, previous research with this sample reported high levels of
bidirectional IPV—where individuals reported both IPV perpetration and victimization (Forster
et al., under review). However, this study operationalized IPV as unidirectional (victimization or
perpetration) instead of bidirectional (victim, perpetrator, or both) and this may have biased the
results limiting their generalizability. Finally, data was collected by self-report and there is a
possibility of recall bias and social-desirability when answering questions of a sensitive nature.
The results of this investigation provide evidence of a temporal relationship between
alcohol use involvement and physical IPV perpetration. However, alcohol use problems may not
be predictive of other types of IPV perpetration or victimization. The latter is particularly
important as these findings suggest that problematic alcohol use may engender physical
responses during spousal conflicts, but does not increase susceptibility to victimization of other
forms of IPV. More research is needed to understand the proximal and distal risk factors for
perpetrating other forms of IPV in emerging adult Hispanic populations. Finally, the evidence
that alcohol use problems and perceived discrimination have a multiplicative effect on the
77
likelihood of physical IPV perpetration in an unexpected direction should be replicated to
ascertain whether such an association is occurring or might have been the result of chance.
CHAPTER 6: GENERAL DISCUSSION AND CONCLUSION
What this work adds to the literature
The cumulative findings of this research contribute to our understanding of problematic
alcohol use among emerging adult populations in several ways. First, this work identified
important cultural variables related to the expression of problematic alcohol use and contributes
to our theoretical understanding of problem alcohol use. Specifically, perceived discrimination
was identified as a prospective risk factor for experiencing negative consequences among
Hispanic alcohol users. While reverse associations were noted, this finding adds to a growing
body of literature implicating perceived discrimination as a meaningful risk factor for negative
health behaviors in ethnic minority groups such as Hispanics (Torres & Vallejo, 2015; Unger et
al., 2016). Interestingly, perceived discrimination was a risk factor for alcohol use problems, but
not alcohol use frequency, among those reporting alcohol use at EA waves 3 and 4. As
operationalized in the present studies, perceived discrimination is best characterized as an
ultimate influence on behavior given that it reflects a broad and relatively stable perception of
one’s environment. Capturing specific instances of discrimination that immediately precede
(proximal influence) alcohol misuse would be an interesting line of future inquiry Further, ethnic
identity may be important in understanding positive experiences that result from drinking that
may offset personal appraisals of negative consequences. However, it does not appear that
stronger identification with one’s ethnic group will offset the effects of perceived discrimination
on problematic alcohol use and specific cultural values, such as familism, may not be relevant
protective factors from problematic alcohol use either. Of equal importance, the statistical
models controlled for peer alcohol use and depressive symptomology, influences from the social
78
and biological/intrapersonal stream. Lack of attention to other important influences has been
cited as a common criticism of cultural research (Ratner & Hui, 2003; Hatala, 2012) and the use
of a broader theoretical framework in these studies gives more weight to the observed
associations and conclusions drawn here. The majority of findings from the present work are in
agreement with theoretical models and previous research suggesting that social situations and
biological or personality related factors contribute to alcohol use outcomes.
Second, while previous research has linked problem alcohol use severity to IPV (Foran &
O’Leary, 2008a) this work builds on previous findings. In particular, this sample was drawn
from community, as opposed to clinical, settings reducing the possibility of ceiling effects
thereby producing more reliable estimates of the relationship between problem alcohol use and
IPV. Female alcohol users appeared equally, or more, likely to report victimization and
perpetration of IPV in several instances disillusioning conventional beliefs that IPV is specific to
male perpetrators. The number of alcohol use problems reported by individuals was
prospectively associated with physical IPV perpetration and victimization while level of
perceived discrimination was only prospectively related to IPV perpetration. In addition, it
appears that perceived discrimination (an ultimate distal influence) and problematic alcohol use
(a proximal predictor) may interact suggesting that experiencing both risk factors may indicate
additional dysfunction. Intervening to reduce perceptions of discrimination could alter the
likelihood of experiencing physical IPV in romantic settings where related proximal factors play
an important role, but more work is needed to understand if and how this can be achieved.
Finally, the present line of research used a community based sample of Hispanic
emerging adults whereas the majority of the existing work on problematic alcohol use has
focused on disproportionately non-Hispanic White participants from college settings (Mallett et
79
al., 2013; White & Hingson, 2014). The work presented here provides evidence of important
intrapersonal, social and cultural factors related to the experience of negative alcohol use
consequences in Hispanic emerging adults and also extends the findings to understand how
problem alcohol use relates to other negative health behaviors (i.e., intimate partner violence).
What remains unknown?
There were limitations to this work that weakens the practical implications of the findings
presented herein. While several of these are mentioned throughout the individual chapters, they
are highlighted here again. First, only a limited number of alcohol-related negative consequences
drawn from the Rutger’s Alcohol Problem Index (RAPI) were assessed in these studies. This
limits the ability of these studies to assess the true level of problematic alcohol use that is being
experienced by this sample. Moreover, the items focus more on psychological and physical
consequences of use than on micro (e.g., fighting with friends) or macro (e.g., drunk driving)
level social consequences. In addition, while we limited the study samples to alcohol users there
is a possibility that individuals experienced these consequences as the result of using other drugs
or combining other substances with their alcohol use. Second, these studies used self-report
measures to collect data. This may be problematic as participants may have under- or over-
reported some behaviors or feelings due to social desirability (presenting oneself in a manner
they perceive that others would expect or deem acceptable). Moreover, the measure of perceived
discrimination used for these analyses could not assess the chronicity or context in which
discrimination took place, or provide an “objective” corroboration. Third, our sample was
constituted of primarily second and third generation Mexican American emerging adults from
Southern California. We also experienced attrition between the high school and emerging adult
studies. Attrition analyses suggest that the sample may have been lower risk in terms of alcohol
and drug use involvement and disproportionately female. This further limits our ability to
80
generalize these findings to other Hispanic/Latino subgroups or to other groups of emerging
adults engaged in alcohol use. Fourth, these findings cannot be generalized to explain
problematic use of substances other than alcohol as this work focused specifically on alcohol use
consequences. Finally, we cannot rule out the possibility that participants were experiencing
clinical alcoholism (Morse & Flavin, 1992) as the present study did not involve a clinical facet to
evaluate alcohol use disorders.
These limitations should be interpreted as recommendations for future research endeavors
in this field. First, future work should attempt to use balanced short scales of alcohol use
problems such as the Short Inventory of Problems (SIP; Kiluk et al., 2013) or other equitable
scales to capture consequences experienced in numerous domains of functioning while reducing
the burden on participants from filling out longer measures. Second, researchers should seek to
collect corroborative data through field methods such as the portal survey technique—a
multimodal assessment technique—to alcohol and drug use in high-risk settings or with
populations that are difficult to track (Voas et al., 2006; Kelley-Baker, Voas, Johnson, Furr-
Holden, & Compton, 2007). Finally, it is recommended that researchers attempt to expand these
findings to understand the role of intrapersonal, social and cultural factors in understanding
misuse of substances other than alcohol. Given the differences in the biological effects of
different drugs on the brain, it is important to understand if and how risk and protective factors
vary by substance use preference. Some research has begun investigations into general substance
use consequences, but the majority of work to date has focused on either how other substances
increase risk for alcohol related problems (Baggio et al., 2014; Stein, Caviness, & Anderson,
2014; Steers, Neighbors, Christina Hove, Olson, & Lee, 2015) or have focused on other specific
types of drugs, such as club drugs (Parks & Kennedy, 2004) or non-medical use of prescription
81
drugs (Kelly et al., 2013). Finally, it is important to acknowledge that alcoholism develops and
manifests from a combination of environmental, psychosocial, and genetic factors. As statistical
models become more efficient at producing reliable estimates from complex models, researchers
should endeavor to examine the simultaneous influence of the many purported theoretical
influences on alcohol use and misuse.
Where do we go from here?
The lack of support for several hypotheses in the current investigation should not deter
researchers from exploring relevant cultural factors in our understanding of alcohol related
negative consequences among ethnic minority groups.
In study one, there were no observed relationships between three cultural values
(familism, respeto, and fatalism) with alcohol related negative consequences cross-sectionally or
longitudinally. However, it should be noted that the surveys did not include other—potentially
important—cultural values. For example, several prior studies have noted gender differences in
the manifestation of alcohol related negative consequences in adolescent and young adult
samples (for review, see Nolan-Hoekesema, 2004; Grigsby et al., 2016; Mallett et al., 2013) with
males reporting more alcohol related negative consequences than females. A possible
explanation for this robust finding may be in the perception of gender norms. In Hispanic
cultures, gender norms are described in several ways, as machismo (positive and negative
masculine traits such as dignity, hard work, physical strength, male dominance) and marianismo
(positive and negative feminine traits such as modesty, purity, motherly, and self-giving), for
example. The reason for our statistically non-significant findings may be the result of focusing
on the wrong cultural values.
On the contrary, the hypotheses surrounding the role of perceived discrimination in
studies two and three were generally supported in this work and add to the growing body of
82
literature that experiencing discrimination from peers, authority figures and institutions can
contribute to negative health outcomes (see Pascoe & Smart Richman, 2009). However, this and
other research has lacked the capability to assess the true nature of the relationship between
discrimination and health behavior. To address this limitation, and measurement concerns, it is
recommended that future research attempt to develop measures of discrimination that can be: a)
used to assess chronicity and source of exposure and b) corroborated with other evidence. This is
challenging as perceptions of discrimination can vary considerably considering the context of the
discriminatory event and the overtness of the discriminatory action. For instance,
microaggressions—subtle yet offensive verbal and nonverbal communication targeting minority
or marginalized groups—are difficult to perceive or respond to immediately and may not be
apparent until multiple exposures have occurred. Improving our understanding of the myriad
discriminatory acts, motivations and responses will improve the ability of researchers and
clinicians to identify and ameliorate the negative outcomes associated with experiencing
perceived discrimination.
These findings did not suggest that higher levels of ethnic identity buffer the negative
effects of perceived discrimination on experiencing negative consequences from alcohol use.
This had been hypothesized as stronger identification with one’s ethnic group and cultural values
could, theoretically, serve as a coping mechanism from discrimination. However, members of
other ethnic groups and members of one’s own ethnic group can perpetrate discrimination.
Discrimination does not stem solely from an individuals’ cultural background, but can instigated
by a person’s physical appearance, speech, sexual orientation, age and other individual factors.
Moreover, acculturated or U.S. born Hispanics may discriminate against recent immigrants or
those with stronger Hispanic traits in order to “fit in” with the dominant cultural group in their
83
community (Telles & Murgia, 1990; Arellano-Morales et al., 2015). The present study did not
explore this possibility and it should not be ruled out as a causal explanation for the observations
described here. More work is needed to understand why people feel they are being discriminated
against in order to identify protective factors that can offset the negative effects those actions
may have on their future health.
It is also important that these results be replicated in other ethnic minority groups to
better understand the role of culture in the incidence and manifestation of alcohol-related
negative consequences. Other racial/ethnic minority groups have been observed as having higher
rates of misuse and abuse of alcohol relative to non-Hispanic Whites (Muthen & Muthen, 2000;
Mulia, Greenfield & Zemore, 2009). Some cultural stressors, such as perceived discrimination,
and cultural assets, such as stronger family bonds, may be shared among ethnic minority groups.
It is paramount that future research identify shared cultural risk and protective factors using
multiethnic samples in order to modify existing problem alcohol use interventions that, to date,
have primarily been developed based on data collected from non-Hispanic White college
students (Miller et al., 2013; Tanner-Smith & Lipsey, 2015). While universal prevention
programs target important casual factors of negative alcohol use consequences the present
studies show that unique cultural factors should not be ignored. Moreover, research with
multiethnic samples may also elucidate unique traits, values and experiences that lead to
problematic alcohol use in this developmental stage which would be useful given the current
direction into tailored personalized feedback interventions that are currently being explored in
intervening on problematic alcohol use among young adults (Miller et al., 2013).
Finally, we observed interesting similarities in the prediction of positive and negative
alcohol use consequences in study three. The majority of positive alcohol consequences are
84
social in nature and most drinking in emerging adulthood takes place in social situations.
Experiencing immediate, socially beneficial consequences from drinking may reduce appraisals
of negative consequence severity especially in groups experiencing socially based stress (i.e.,
perceived discrimination). Future research would benefit from exploring whether positive
consequences are reported more frequently, or with greater intensity, among subgroups of
Hispanic alcohol users experiencing higher levels of perceived discrimination. Understanding the
complex interplay between environmental stressors that make alcohol use rewarding in spite of
experiencing concurrent negative outcomes—such as blacking out or neglecting
responsibilities—can improve our understanding of problematic alcohol use among Hispanic
emerging adults and may be a valuable prevention target to reduce substance use and negative
health behaviors across the lifespan (Sussman, 2013).
Conclusion
Current substance use and misuse interventions tailored to, or adapted for use with,
Hispanic communities typically focus on strengthening ethnic identity, improving family
communication, embracing diversity, and teaching refusal self-efficacy skills that are consistent
with Hispanic cultural values (Tomaka, Palacios, Morales-Monks, & Davis, 2012; Cordova et
al., 2012). The findings of the present investigation suggest that such curricula may not be
effective at reducing negative alcohol use consequences among Hispanic emerging adults there
were no significant longitudinal associations between alcohol related negative consequences with
salient cultural values (familism, respeto, fatalism).
It does appear, however, that perceived discrimination may be an underlying source for
problematic alcohol use among Hispanic emerging adults. Perceived discrimination was
prospectively associated with positive and negative alcohol use consequences in study two and
was a significant risk factor for IPV perpetration in study three. While the role of perceived
85
discrimination, and exposure to chronic discrimination, may be underappreciated in the general
scientific literature, the results of the present studies suggest that a greater research focus is
needed to understand the causal pathway from exposure to discrimination and subsequent
negative health behaviors. While previous research has addressed perceived discrimination as a
risk factor for substance use (Unger et al., 2014), these findings suggest that perceived
discrimination may not lead to increased frequency of use but does influence the positive and
negative outcomes that result from drinking among alcohol users (Otiniano Verissimo, Grella,
Amaro, & Gee, 2014; Cheng & Mallinckrodt, 2015). For example, someone experiencing
discrimination may use alcohol as a ‘social lubricant’ and their resulting behaviors may not be
due to a physiological impairment but a deviation in psychological acuity. This would imply that
alcohol serves as a sufficient, but not necessary cause, of the positive and negative outcomes
discriminated individuals report and would explain the findings presented here. This is an
important finding as it suggests alcohol use outcomes can be modified by addressing previous
experiences with discrimination even when non-significant changes in the amount of alcohol
being consumed is observed. Integrating perceived discrimination into prevention programming
for ethnic minority youth and young adults can help to offset the degree of alcohol use
involvement that results in experiencing negative consequences in multiple domains of
functioning. Relative to non-Hispanic Whites, Hispanic youth have evidenced greater baseline
knowledge of stereotyping and less significant changes in knowledge from educational programs
(Sussman, Yang, Baezconde-Garbanati, & Dent, 2003). The findings of this work support
previous calls for deep structural changes to existing prevention programs (Sussman, 2005;
Colby et al., 2013) in order to address the negative effects of perceived discrimination among
86
Hispanic populations using techniques to enhance active coping or promote mindfulness, for
example.
While these results are preliminary and should be replicated, the evidence presented in
this work implicates perceived discrimination as a probable root cause for problematic alcohol
use. However, more work is needed to understand the mechanisms underlying the observed
relationships described here and to identify modifiable characteristics that can offset the adverse
impact perceived discrimination has on problematic alcohol use and associated negative
behaviors, such as IPV. Simply associating with one’s cultural group (having higher scores on
ethnic identity measures) or embodying salient cultural traits and values (familism, respeto,
fatalism) may not be enough to buffer the negative impact of experiencing discriminatory acts.
Using the Theory of Triadic Influence as a guide, and recognizing that discrimination can
be attributed to multiple characteristics, it would be useful for researchers to conduct multiethnic
research in order to identify universal protective factors that can be emphasized in prevention
programs with different groups of individuals. For example, there may be a dearth of active
coping skills that could improve individual’s reactions to discrimination (Villegas-Gold & Yoo,
2014) and modifying psychological and behavioral reactions through education and advocacy
may be warranted. Alternatively, enhancing mindfulness—non-judgmental attention and
awareness of the present moment (Brown-Iannuzzi et al., 2014)—can help minority groups
separate the actions of others from impeding on their self-worth and position in society. In sum,
more research is needed to identify universal or culturally distinct protective factors that can be
modified in intervention and treatment settings to reduce the impact of problematic alcohol use
among emerging adults from ethnic minority backgrounds throughout the lifespan.
87
Figure 1. Theoretical model guiding dissertation studies. Note: Paths of interest à Red = study
1, Blue = study 2, Green = study 3
88
Figure 2. Paths of theoretical model tested in study 1. Note: Multiple group models used to
compare differences in relationships among constructs by gender.
89
Figure 3. Paths of theoretical model tested in study 2 excluding covariates (gender, cultural
values, depressive symptomology).
90
Figure 4. Paths of theoretical model tested in study 3.
Perceived
discrimination
x
alcohol
use
problems
Perceived
discrimination
Adverse
childhood
events
IPV
perpetration
and
victimization
Alcohol
use
problems
Gender
Depressive
symptomology
Peer
substance
use
91
Study 1 – Table 1. Descriptive statistics by gender and for the analytic sample.
Females (n=207) Males (n=210) Total (n=417)
Variable M SD M SD t M SD
Familism 1 13.5 2.4 13.8 2.1 -1.63 13.6 2.3
Familism 2 13.3 2.3 13.4 2.2 -0.89 13.3 2.3
Familism 3 13.2 2.3 13.3 2.2 -0.40 13.3 2.3
Familism 4 13.2 2.4 13.2 2.4 -0.02 13.2 2.4
Respeto 1 15.2 1.9 15.3 1.6 -1.01 15.2 1.8
Respeto 2 15.2 1.8 15.1 2.0 0.82 15.1 1.8
Respeto 3 15.2 1.7 15.0 2.0 1.43 15.1 1.9
Respeto 4 15.0 1.9 14.9 2.2 0.81 15.0 2.0
Fatalism 1 9.4 2.9 9.8 3.1 -1.54 9.6 3.0
Fatalism 2 9.3 3.0 9.3 3.0 0.20 9.3 3.0
Fatalism 3 9.6 3.0 9.8 3.0 -0.57 9.7 3.0
Fatalism 4 9.6 2.9 9.7 3.3 -0.38 9.6 3.0
Ethnic identity 35.2 6.6 34.9 6.8 0.61 35.0 6.7
Peer alcohol use 3.2 0.8 3.3 0.8 -2.51* 3.3 0.8
Depression (CES-D) 10.9 5.5 9.4 4.5 4.22*** 10.3 5.2
Alcohol use frequency 2.5 0.9 2.9 1.0 -5.47*** 2.7 0.9
ARNCs 1 0.8 1.8 1.5 2.9 -3.70*** 1.1 2.3
ARNCs 2 1.2 2.5 1.6 2.9 -2.00* 1.3 2.7
ARNCs 3 1.1 2.0 1.6 2.7 -3.22** 1.3 2.3
ARNCs 4 1.2 2.4 1.9 3.3 -3.12** 1.5 2.8
Note: Numbers after constructs indicate assessment wave (e.g., ‘1’ = wave 1). Alcohol use frequency
refers to average alcohol use over the four assessment waves. *p<0.05, **p<0.01, ***p<0.001
92
Study 1, Table 2. Univariate growth curve results by gender and for the entire sample of alcohol
users in Project RED.
Intercept Linear slope
M (SE) Variance (SE) M (SE) Variance (SE)
Males 13.66
(0.13)***
1.97 (0.40)*** -0.16 (0.06)** 0.11 (0.10)
Familism Females 13.42
(0.15)***
3.04 (0.77)*** -0.13 (0.05)* 0.09 (0.13)
Total
sample
13.55
(0.10)***
2.54 (0.10)*** -0.15 (0.04)*** 0.10 (0.08)
Males 15.22
(0.12)***
1.50 (0.78) -0.13 (0.05)* 0.11 (0.13)
Respeto Females 15.14
(0.12)***
1.86 (0.48)*** -0.06 (0.05) 0.04 (0.11)
Total
sample
15.18
(0.09)***
1.68 (0.46)*** -0.09 (0.03)** 0.07 (0.08)
Males 9.86 (0.22)*** 6.94 (0.94)*** 0.01 (0.07) 0.22 (0.17)
Fatalism Females 9.34 (0.19)*** 5.60 (0.77)*** 0.15 (0.07)* 0.43 (0.15)**
Total
sample
9.60 (0.14)*** 0.31 (0.62) 0.08 (0.05) 0.32 (0.12)**
Males 2.15(0.07)*** 0.50(0.12)*** 0.10(0.03)*** 0.04(0.03)
Alcohol use
frequency
Females 1.92(0.06)*** 0.41(0.13)** 0.14(0.03)*** 0.05(0.03)
Total
sample
2.04 (0.05)*** 0.47 (0.09)*** 0.12 (0.02)*** 0.05 (0.02)*
Males 1.75(0.19)*** 4.80(2.33)* 0.14(0.07) 0.14(0.20)
NAUCs Females 1.15(0.14)*** 2.65(0.83)** 0.25(0.07)*** 0.32(0.12)**
Total
sample
1.47(0.12)*** 3.74 (1.25)** 0.19 (0.05)*** 0.20 (0.13)
Notes: n = 417 (207 male, 210 female). NAUCs = negative alcohol use consequences, M =
mean, SE=Standard Error. *p<0.05, **p<0.01, ***p<0.001
93
Study 1, Table 3. Univariate growth models for non-alcohol users (n=1,178) in Project RED study.
Intercept Slope
M(SE) Variance(SE) M(SE) Variance(SE)
Respeto Male 15.08(0.10)*** 2.69(0.64)*** -0.13(0.05)** 0.23(0.12)
Female 15.40(0.06)*** 1.47(0.34)*** -0.13(0.03)*** 0.18(0.06)***
Total 15.27(0.08)*** 1.93(0.42)*** -0.14(0.03)*** 0.22(0.07)***
Familism Male 13.39(0.13)*** 4.80(0.72)*** -0.15(0.06)** 0.30(0.13)*
Female 13.62(0.09)*** 2.75(0.47)*** -0.20(0.04)*** 0.18(0.10)
Total 13.52(0.10)*** 3.51(0.53)*** -0.19(0.05)*** 0.24(0.11)**
Fatalism Male 9.70(0.15)*** 4.56(0.82)*** 0.05(0.06) 0.17(0.19)
Female 9.99(0.12)*** 5.66(0.61)*** 0.06(0.05) 0.33(0.13)*
Total 9.89(0.09)*** 5.22(0.48)*** 0.06(0.04) 0.27(0.10)*
Note: (n=1,178; males=463, females = 715). M=Mean, SE = Standard Error. *p<0.05, **p<0.01, ***p<0.001.
94
Study 1 – Table 4. Results from final parallel process LGM model on the correlations between predictors
and the initial status and rate of change in alcohol use outcomes.
Alcohol use frequency Alcohol related negative
consequences
r p r p
Correlations with intercept
Respeto (I) – intercept 0.07 0.44 -0.21 0.35
Familism (I) – intercept -0.02 0.87 -0.26 0.46
Fatalism (I) – intercept 0.11 0.53 0.04 0.90
Alcohol use frequency (I)– intercept -- -- 0.61 0.002
Peer alcohol use – intercept 0.19 <0.001 0.10 0.21
Depression – intercept 0.06 0.85 0.35 0.41
Ethnic identity – intercept -0.42 0.29 0.16 0.83
Correlations with slope
Respeto (I) – slope -0.05 0.29 0.04 0.66
Familism (I) – slope 0.02 0.72 0.06 0.65
Alcohol use frequency (I) – slope -- -- 0.06 0.45
Fatalism (I) - slope -0.09 0.27 -0.13 0.57
Respeto (S) – slope <0.001 0.98 0.01 0.75
Familism (S) – slope -0.04 0.11 -0.05 0.25
Alcohol use frequency (S) - slope -- -- 0.06 0.04
Peer alcohol use – slope -0.01 0.68 -0.06 0.19
Depression – slope 0.02 0.91 0.34 0.42
Ethnic identity – slope -0.09 0.70 0.21 0.52
Note: (1) = intercept value, (S) = slope value. r = correlation coefficient.
95
Study 2 – Table 1. Descriptive statistics of study variables for analytic sample (n=710).
Variable M SD
Perceived discrimination 17.5 5.8
Ethnic identity 3.1 0.5
Alcohol use frequency 2.1 1.1
Depression 7.6 6.0
Peer alcohol use 3.5 0.7
Negative alcohol use consequences 1.1 1.6
Positive alcohol use consequences 5.5 4.2
f %
Gender (1=Male) 295 41.6
Note: M=mean, SD = standard deviation, f = frequency, % = percent
96
Study 2 – Table 2. Results from negative binomial regression models predicting positive and negative
alcohol use consequences.
Variable Negative consequences Positive consequences
IRR 95% CI IRR 95% CI
Perceived discrimination 1.03 1.01, 1.04 1.01 1.00, 1.02
Ethnic identity 1.11 0.90, 1.37 1.18 1.03, 1.36
Alcohol use frequency 1.66 1.54, 1.79 1.33 1.27, 1.41
Male 1.21 1.00, 1.04 1.15 1.01, 1.30
Depression (CES-D) 1.03 1.01, 1.04 1.00 0.99, 1.01
Peer alcohol use 1.20 1.05, 1.38 1.28 1.18, 1.40
Note: IRR = adjusted incidence-rate ratio, 95% CI = 95% confidence interval. Significant
findings in bold.
97
Study 2, figure 1 (a and b). Lowess smoothing plots exploring the relationship between alcohol
use frequency with negative (a) and positive (b) alcohol use consequences.
1 2 3 4 5
Quantity of alcohol use problems (past 30 days)
1 2 3 4 5 6
Past 30 day alcohol use
(a) Negative alcohol use consequences
4 5 6 7 8 9 10
Quantity of positive alcohol use consequences
1 2 3 4 5 6
Past 30-day alcohol use
(b) Positive alcohol use consequences
98
Study 3 - Table 1. Descriptive statistics of study variables for analytic sample
Males
(n= 404)
Females
(n = 600)
Total sample
(n = 1,004)
Variable M SD M SD t M SD
Alcohol problems 1.54 3.05 1.00 2.30 3.22** 1.22 2.64
Perceived discrimination 18.20 6.85 17.28 6.03 2.24* 17.65 6.31
ACE-verbal 2.34 2.03 2.09 2.13 1.84 2.13 2.16
ACE-physical 1.55 1.82 1.34 1.02 1.80 1.39 1.87
ACE-interparental IPV 0.70 1.95 0.85 2.18 0.85 0.87 2.25
f % f % χ
2
f %
IPV victimization
Psychological 183 45.8 299 50.5 2.06 482 48.6
Physical 61 15.1 69 11.5 2.88 130 12.9
Sexual 57 14.1 78 13.0 0.26 135 13.5
IPV perpetration
Psychological 177 43.8 336 56.0 14.45*** 513 51.1
Physical 41 10.2 101 16.8 8.88** 142 14.1
Sexual 60 14.9 43 7.2 15.49*** 103 10.3
Note: M = mean, SD = standard deviation, f = frequency, % = percent, t=t-test, χ
2
= chi-square
*p<0.05 **p<0.01 ***p<0.001; ACE=Adverse Childhood Event; CES-D=Center for Epidemiological
Studies-Depression Scale
99
Study 3 - Table 2. Results of final logistic regression models predicting psychological, physical and
sexual IPV victimization for analytic sample (n=1,004).
Psychological Physical Sexual
Variable OR 95% CI OR 95% CI OR 95% CI
Male 0.78 0.60, 1.01 1.31 0.89, 1.92 1.02 0.70, 1.49
ACE-verbal 1.12 0.93, 1.35 0.95 0.72, 1.24 1.39 1.08, 1.79
ACE-physical 1.04 0.86, 1.26 1.26 0.97, 1.62 1.19 0.93, 1.51
ACE-interparental IPV 1.06 0.90, 1.24 1.16 0.96, 1.40 1.04 0.87, 1.26
Alcohol problems (AP) 1.01 0.87, 1.16 1.20 1.04, 1.39 1.03 0.88, 1.22
Perceived discrimination (PD) 1.01 0.99, 1.03 1.02 0.99, 1.06 1.03 0.99, 1.06
APxPD 1.00 0.99, 1.01 0.99 0.98, 1.01 1.00 0.99, 1.01
Note: OR = Adjusted odds ratio, 95% CI = 95% confidence interval. Bold OR values are significant
(p<0.05). Models were adjusted for peer alcohol use and depressive symptomology.
100
Study 3 - Table 3. Results of final logistic regression models predicting psychological, physical and
sexual IPV perpetration for analytic sample (n=1,004)
Psychological Physical Sexual
Variable OR 95% CI OR 95% CI OR 95% CI
Male 0.55 0.42, 0.72 0.52 0.35, 0.77 2.16 1.41, 3.30
ACE-verbal 1.19 0.99, 1.45 1.08 0.84, 1.40 1.20 0.90, 1.60
ACE-physical 0.98 0.81, 1.19 1.17 0.91, 1.51 1.47 1.12, 1.91
ACE-interparental IPV 1.02 0.86, 1.21 1.06 0.88, 1.28 0.87 0.69, 1.11
Alcohol problems (AP) 1.01 0.87, 1.18 1.27 1.08, 1.49 1.10 0.93, 1.32
Perceived discrimination (PD) 1.01 0.99, 1.04 1.03 1.01, 1.07 1.03 0.99, 1.07
APxPD 1.00 0.99, 1.01 0.98 0.97, 0.99 0.99 0.98, 1.01
Note: OR = Adjusted odds ratio, 95% CI = 95% confidence interval. Bold OR values are significant
(p<0.05). Models were adjusted for peer alcohol use and depressive symptomology.
101
Study 3 - Figure 1. Visual representation of the relationship between perceived discrimination (PD) at
fixed estimates of alcohol use problems in EA time 2 on the predicted probability of physical IPV
perpetration at EA time 3 with 95% confidence intervals.
0 .2 .4 .6 .8 1
Predicted probability of physical IPV perpetration (T3)
1 2 3 4 5 6 7
Quantity of alcohol use problems (T2)
1st quartile of PD 2nd quartile (median) of PD
3rd quartile of PD
102
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Abstract (if available)
Abstract
Alcohol use problems are the proximal and negative consequences of alcohol use and can impact functioning in multiple domains of life. Research has yet to investigate the influence of cultural variables in larger theoretical models of problem alcohol use behavior. The current scholarly work aims to clarify and highlight the impact of the sociocultural experience on alcohol use outcomes in order to better integrate relevant cultural variables into alcohol misuse prevention and intervention services for minority emerging adults. These studies are designed to fill the gap in whether culture-specific factors and experiences influence alcohol related negative consequences and related behaviors in a community sample of Hispanic emerging adults while adjusting for known intrapersonal (i.e., depression) and interpersonal (i.e., peer alcohol use) factors. Study 1 tests hypotheses that the salient cultural values (familism, respeto, fatalism) are associated with the alcohol use frequency and related negative consequences over time. Study II explores whether perceived discrimination leads to more positive and negative alcohol use consequences and whether higher levels of ethnic identity buffer this relationship. Finally, study III extends the findings of study II to explore whether alcohol use problems and perceived discrimination lead to an increase in the probability of experiencing intimate partner violence (IPV). As a whole, these studies were able to identify shared and unique features of etiological processes of problem alcohol use for Hispanic emerging adults and confirm that sociocultural stressors increase risk for negative alcohol use consequences. Among the most notable findings is the consistent relationship between perceived discrimination and alcohol use outcomes. Future studies would benefit from further exploration of the role cultural stressors play in alcohol and drug use behaviors in ethnic minority populations.
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Grigsby, Timothy J.
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Problematic alcohol use in Hispanic emerging adults: the role of perceived discrimination, cultural identity, and salient cultural values
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Keck School of Medicine
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Doctor of Philosophy
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Preventive Medicine (Health Behavior Research)
Publication Date
07/05/2016
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