Contextual approach to immigration challenges among Cuban women

doi:10.21203/rs.3.rs-3117626/v1

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Contextual approach to immigration challenges among Cuban women

https://doi.org/10.21203/rs.3.rs-3117626/v1

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Purpose: Much of the research examining the impact of acculturation on mental health draws conclusions based on samples from Mexican populations or Latinos overall, concealing the cultural diversity among Latino subgroups. This study highlights unique experiences of Cuban-born women in the U.S. by comparing their acculturative stress experience to that of Latina immigrants combined (i.e. Latinas born in Mexico and Puerto Rico)

Methods: We included 639 Latinas and 264 Cuban-born Latinas using National Latino Asian American Study (NLAAS). Based on Family Stress Management theory and existing research, we hypothesized that: (a) different contexts influence acculturative stress and psychological distress differently, therefore they should be studied as distinct concepts; (b) contextual factors interact with each other in influencing acculturative stress and psychological distress, and (c) the relationships between contextual factors, acculturative stress, and psychological distress among Cuban-born women differ from that of Latina immigrants combined.

Results: We found full support for the hypothesis (a) when controlling for socio-economic context, English skills, visiting family abroad difficulties, perceived racial discrimination and family-culture conflict, years in the U.S. interacted with perceived racial discrimination to affect acculturative stress among Latina immigrants combined showing partial support for hypothesis (b). Six contextual factors impacted acculturative stress of Cuban-born women vs. eight for Latina immigrants combined, and three contextual factors impacted psychological distress of Cuban-born women, vs. six for all Latina immigrants supporting hypothesis (c).

Implications. Country of birth differences suggest a need for further research focusing on Latino subgroup experiences with acculturation to inform effective policy and practice that targets unique needs of Latino sub-groups.

Psychology

Cuban women

acculturation

discrimination

acculturative stress

Research on the impact of acculturation on Latino immigrants' mental health has proliferated in recent years, with many studies focusing on acculturation, or the process of cultural and psychological change resulting from contact between two or more cultural groups and their members (Berry, 2005). Much research has supported the benefits of acculturation among Latino immigrants, such as more significant social networks, eventual socioeconomic integration, and improved educational outcomes (Kim et al., 2021). However, a smaller body of literature links acculturation with poor mental health (i.e., depression, anxiety, and suicidal ideation [Klein et al., 2021, 2012; Crockett et al., 2007; Torres, 2010]). Researchers have identified acculturative stress—or the stress related to the attempts to adopt a dominant culture's beliefs, practices, and values (Berry, 1997)—as a significant mediator between acculturation and mental health, which helps explain some of the inconsistent results in acculturation research. However, acculturative stress remains poorly investigated, resulting in an incomplete understanding of acculturation's impact on the lives of Latino immigrants.

Within the relatively thin body of research on the determinants of acculturative stress, Latinos tended to be grouped, undermining the vast cultural and socioeconomic heterogeneity across Latino ethnicities. Very little research exists on Cuban Latinos' experience with acculturative stress, even though Cubans are a particularly unique Latino sub-group. Cuban Latinos, who number 11.6 million and makeup 3.5% of Latinos in the U.S. (Pew Hispanic Center, 2010), report higher rates of citizenship, college graduation, and home ownership than other Latino sub-groups. Cuban Latinos are likely to be older, report higher levels of education, and earn higher incomes (Andrade & Viruell-Fuentes, 2011; Pew et al., 2010). Furthermore, Cuban Latinos' initial entry into the U.S. under refugee status and the federal aid that accompanied their arrival created a unique and more positive context of reception in the U.S. (Andrade & Viruell-Fuentes, 2011; Perez, 2011). This legacy is reflected in the geographic dispersion of Cuban immigrants and descendants, who tend to live in Miami and other urban centers (e.g., New York) (Cislo et al., 2010).

The tendency to group Latinos runs the risk of concealing experiences that Cuban Latinas experience as women. The stress from balancing multiple roles that Cuban Latinas often experience, traditional gender-based roles, and the tendency to follow traditional Latino-specific beliefs (Goodkind et al., 2008) are highlighted in the acculturation experience of Cuban-born women. Furthermore, due to the geographic concentration of Cuban families in specific pockets of the U.S., Cuban-born Latinas tend to enjoy a more robust support network and exercise a more significant political influence than other Latina immigrants (e.g., Mexican women) who are dispersed throughout the country are likely to face challenges such as precarious immigration status, lower socioeconomic status, and higher unemployment rates (Bonning & Brown, 2002). However, unlike some Latino sub-groups (e.g., Puerto Ricans), Cuban immigrants may find ongoing contact with extended family challenging, despite recent efforts to improve political relationships between the U.S. and Cuba (Burgos, 2002).

These contexts have been theorized to influence levels of acculturative stress among immigrants. However, by drawing conclusions based on samples primarily consisting of Mexican immigrants, the unique experiences of Cuban immigrants have been overlooked, compromising the development of culturally-sensitive mental health policies and practices. Although Cuban Latinas report lower acculturative stress than other Latino sub-groups (Bonnin & Brown, 2002), mental health and stress are nevertheless critical issues affecting the Cuban diaspora in the U.S. This theory-guided, comparative analysis of acculturative stress and psychological distress among Cuban-born women and Latina immigrants combined aims to further the knowledge on the impact of acculturative stress on mental health among Cubans. By setting forth evidence of the differences in relationships between contextual factors, psychological distress, and acculturative stress among Cuban-born women and Latina immigrants combined, we shed light on the unique experiences of Cuban women. The findings aim to inform the development of culturally sensitive mental health interventions targeting

Cuban-born women

Cuban Women and Acculturative Stress

To estimate the impact of various contextual factors on acculturative stress and psychological distress among Cuban-born women, we first summarize the theoretical and empirical research that identifies these contextual factors. Although limited, this body of existing research highlights several contexts which shape Cuban-born women's experience, including familismo, family-culture conflict, gender-based roles, education, income, U.S. region of residence, English skills, religiosity, inclusion in decision-making to emigrate, difficulties with visiting family in Cuba, being a woman, exposure to and perception of discrimination, length of time in the U.S., contentment with the decision to immigrate to the U.S., marital status, age at immigration, 9/11 impact and age (Gil & Vega, 1996; Rivera et al., 2008; Szapocznik & Hernandez, 1988; Szapocznik & Kurtines, 1980; Bonnin & Brown, 2002; Burgos, 2002; Gil & Vega, 1996; Rivera et al., 2008). The section below discusses these contexts at a greater length.

Familismo, which defines the family structure and family relations among Latinos in general and is a theme explored across various Latino groups, is among the most salient contexts (e.g., Bonnin & Brown, 2002; Burgos, 2002; Gil & Vega, 1996; Gonzalez, 1980; Rivera et al., 2008; Szapocznik & Hernandez, 1988; Szapocznik & Kurtines, 1980; Szapocznik et al., 1978). Cuban identity, self-confidence, and security are embedded in familismo, and the various waves of Cuban migration have imported and reaffirmed this value (Boswell & Curtis, 1984). Familismo is known to diminish and exacerbate acculturative stress among this group of women. Cuban-born immigrants in the U.S. maintain familismo as a primary coping mechanism for acculturative stress, as it provides resource and social support throughout cultural transition (Gil & Vega, 1996). Cuban families can offer Cuban women protection, support, socialization, and resources (Vega, 1990). However, when strong loyalty and family ties clash with the values of independence and individuality, which prevail in the U.S., it becomes a challenge to maintain the value of familismo (Gil & Vega, 1996; Rivera et al., 2008). Family dynamics may shift during cultural transitions, creating new stressors that may disrupt familial bonds, structure, and communication, challenging a Cuban women's sense of purpose and belonging in the U.S. (Bonnin & Brown, 2002).

The family-culture conflict has also been linked to high acculturative stress among Cuban women, often attributed to disparate acculturation rates among family members (Szapoznik & Kurtines, 1980; Szapocznik & Hernandez, 1988). Cuban children, particularly sons, tend to acculturate faster than their parents (Szapocznik et al., 1978). The disparate acculturation patterns over time tend to break down family cohesion, challenge familial hierarchy, and compromise parental authority (Gil & Vega, 1996). Research on Cuban families suggests that when such family-culture conflicts arise within strongly cohered families, high psychological stress is likely to result, particularly among married women (Burgos, 2002).

Among Cuban families, it is primarily adult males who have decided for the family to migrate to the U.S. (Burgos, 2002). Political and, to a lesser extent, economic reasons have typically driven these migration decisions. Some Cuban women report being initially content with the decision to move to the U.S.; however, after moving, they often report feelings of anxiety and shock (Burgos, 2002). In one study, women reported that adjusting to their new environment's climate, the less communal lifestyle and the closed neighborhood design was difficult, which sharply contrasted with their surroundings in Cuba. Research shows that various elements contribute to contentment with the decision to migrate to the U.S. For example, Cuban women who have endured political exile report that the psychological tensions of exile collided with various acculturation stressors, such as language barriers, feelings of loss and isolation, and employment challenges (Gonzalez, 1980). This strained the family unit and caused some women to experience depression and stress, leading them to use coping mechanisms like prescription drug use (Gonzalez, 1980).

The experience with migration and acculturative stress to Cubans is also related to socioeconomic status (e.g., Burgos, 2002; Fernandez, 2007; Rivera et al., 2008; Sanchez et al., 2012; Zsembik & Fennell, 2005). Immigrants arriving in the U.S. during the "Golden Exile" (i.e., prior to 1980) tended to be well-educated and of the upper-middle class, emigrating from Cuba in pursuit of political refuge and welcomed into the U.S. through favorable immigrant policies (Turner et al., 2006; Zsembik & Fennell, 2005). However, most Cuban-born immigrants in the U.S. arriving after the 1980s have come from a lower socioeconomic standing and are more prone to conditions of poverty (Burgos, 2002; Khan et al., 1996; Wang et al., 2010). Among the latter, low socioeconomic status is often maintained even after migration due in part to being forced into low-paying jobs, some of which pay wages below federal and union standards (Burgos, 2002). Lower household income and fewer years of education are associated with higher post-migration acculturative stress for all Latinos, including Cubans (Sanchez et al., 2012; Rivera et al., 2008).

Cuban-born immigrants primarily reside in one area of the U.S., South Florida (Bonnin & Brown, 2002; Burgos, 1996; Gil & Vega, 1996).). However, even when immersed in such entrenched support networks, Cuban-born immigrants are not immune to acculturative stress through language and racial conflicts, which most Latino immigrants endure (Fernandez, 2007; Gil & Vega, 1996; Wang et al., 2010). Among Cuban-born immigrants, acculturative stress tends to be associated with low English language proficiency, an effect that decreases over time (Gil & Vega, 1996). Particularly among U.S.-born Cuban young adults, low proficiency in native and learned languages prompts stressful cultural and psychosocial negotiations, including perceived pressure to acculturate and desired depth of orientation into U.S. culture (Wang et al., 2010).

Research on the role of contexts such as gender-based roles is limited to addressing the impact of changes in traditional gender roles, such as married women's participation in the U.S. workforce on the traditionally male-dominated family structure (Burgos, 2002). Other stress-inducing contexts—i.e., discrimination, length of time in the U.S., marital status, age at immigration, 9/11 impact, and age—remain relatively uninvestigated among Cuban Latinos. However, previous researchers have found these issues to significantly influence the acculturative stress of Latinas in general (i.e., Horevitz & Organista, 2012; Huyny & Devos, 2012; Leung et al., 2014; Zhang et al., 2012).

Theoretical Framework: Family Stress Management Theory; Contextual Influence in Acculturative Stress (CIAS)

Family Stress Management Theory (FSM) (Boss, 20002) is a framework that explains how families cope with stress, the role that contextual factors play in a family's perception and experiences with stress, and the relationship between stress and family members' mental health.

According to FSM (Boss, 2010), the relationship between stress and psychological distress depends on contexts that influence one's perception of stress. FSM theorizes that the amount of stress a family experiences depends on external contexts, such as cultural, historical, and economic contexts that remain largely out of a family's control, and internal contexts, or structural, psychological, and philosophical dimensions the family can control. Existing coping mechanisms also play a role in whether stress is a motivating force or a debilitating experience for family members, noting that stress does not always lead to poor mental health (Boss, 2002) (Fig. 1). Dr. Bekteshi and the team of researchers adopted the FSM to meet the needs of Latina immigrants. They developed the CIAS model (Fig. 2) (Bekteshi et al., 2018) to highlight individual and structural contexts influencing acculturative stress among Latinas. In conjunction with FSM, this research will utilize this model to explore the interactive and individual contextual influence of acculturative stress and psychological distress among Cuban immigrant women. Using the CIAS framework (Bekteshi et al., 2018), we categorize the contexts that impact acculturative stress and psychological distress of Cuban-born women and Latina immigrants into the following categories: external and internal contexts. External contexts consist of

U.S. climate (perceived discrimination, visiting family abroad difficulties, level of contentment with U.S. move, U.S. region of residence and years in the U.S.);

development contexts (education level, age at immigration, age, marital status, and English skills);

economic contexts (financial constraints, employment, and income);

cultural contexts (family-culture conflict and gender-based roles); and

Global context (the impact of 9/11).

Internal contexts are represented by Latino-specific beliefs: familismo and religiosity (Fig. 1).

Based on the FSM and CIAS models, we hypothesize that: (a) different contexts influence acculturative stress and psychological distress differently. Therefore they should be studied as distinct concepts; (b) contextual factors interact with each other in influencing acculturative stress and psychological distress, and (c) the relationships between contextual factors, acculturative stress, and psychological distress among Cuban-born women differ from that of Latina immigrants combined.

Data source and strategy

This study uses the data from the National Latino Asian American Study (NLAAS) (Alegria et al., 2004), the first national population-based mental health study of Latino and Asian Americans. NLAAS was designed in coordination with and as a part of the Collaborative Psychiatric Epidemiology Studies (CPES), which includes NLAAS, the National Survey of American Life, and the National Comorbidity Survey Replication. This survey compared the association of immigration factors with mental health services across three major racial and ethnic categories: African Americans, Asian Americans, and Latino Americans. NLAAS collected extensive information on health and mental health status, behaviors, and health insurance coverage for all age groups. The questionnaire was available in six languages: English, Spanish, Cantonese, Mandarin, Tagalog, and Vietnamese. Trained bilingual interviewers interviewed all NLAAS participants. The study met the approval of three Internal Review Board Committees: Cambridge Health Alliance, the University of Washington, and the University of Michigan (Alegria et al., 2004). The total sample size of the NLAAS data was 4,649, including 2,554 Latinos and 2,095 Asian Americans. The survey included individuals 18 years or older of Latino or Spanish origin who speak English and Spanish. The survey also provided health-related information on the participants (Lewis-Fernández et al., 2009).

Our study sample comprised 264 Cuban-born women and a comparison group of 639 Latina immigrants. The Latina immigrants combined comparison groups of Latinas born in Puerto Rico, Cuba, and Mexico. We incorporated Cuban-born Latinas in the Latina immigrants combined group to mitigate a bias resulting from combining Latina subgroups into one category.

Measures

This study's two dependent variables are acculturative stress and psychological distress. In the past, discrimination has been treated as a part of the acculturative stress experience, with many acculturative stress measures incorporating discrimination (i.e., Hispanic Stress Inventory (HSI)) (Finch et al., 2000). While acculturative stress might correlate with discrimination, discrimination is a particular stressor that separately impacts one's psychological distress (Goodkind et al., 2008). Kulis, Marsiglia, and Nieri (2009) separated discrimination and acculturative stress into two indicators and found that discrimination emerged as a more vital indicator of poor mental health (Kulis et al., 2009). Concurring with Kulis et al. (2009), we posit that while acculturative stress is inherent to one's effort to adapt culturally to a new country, discrimination is related to one's ethnic background and socioeconomic status (Kulis et al., 2009). As such, we exclude discrimination from our acculturative stress measure.

Acculturative stress is measured by adults' self-rated level of agreement on six statements: (1) I felt guilty about leaving family or friends in the country of origin, (2) I have limited contact with family and friends, (3) I find interaction hard due to difficulty with the English language, (4) I was questioned about my legal status, (5) I think I might be deported if I go to a social or government agency, and (6) I avoid health service due to Immigration and Naturalization Services (INS). Possible scores ranged from 0–9, with higher scores indicating a higher level of acculturative stress. Items have been obtained from the Mexican-American Prevalence and Service Survey, which measures the experiences of psychosocial stress for Latinos. The scale has been tested repeatedly for appropriateness in general Latinos (Cervantes et al., 1991) and has high internal consistency (Cronbach is a = 0.88).

The second dependent variable, psychological distress, is measured by Kessler's Psychological Distress Scale consisting of 10 items surveying symptoms of depression and anxiety (K10). A validation study completed in Boston on a small convenience sample found evidence that the scales perform (Kessler et al., 2003). The K10 is also included in the National Comorbidity Survey Replication (NCS-R) as well as in all the national surveys in the World Health Organization (WHO) World Mental Health (WMH) Initiative (Furukawa et al., 2003). Items include responses to the following statements: (1) Past month I felt depressed, (2) Past month I felt hopeless, (3) Past month I felt restless/fidgety, and (4) Past month I felt tired for no good reason (5). The scale's internal consistency is high (Cronbach is a = 0.85).

External context. The first segment of the external context is represented by the U.S. climate, i.e., perceived daily and racial discrimination, visiting family abroad difficulties, contentment with the decision to move to the U.S., U.S. region of residence, and years in the U.S. Perceived discrimination is a two-dimensional construct consisting of perceived racial and daily discrimination. Perceived racial discrimination of adults over 18 is measured by questions such as (1) How often do people dislike you because of your race/ethnicity? (2) Have you seen friends mistreated because of their race/ethnicity? Moreover, (3) How often do people treat you unfairly because of your race/ethnicity? Perceived daily discrimination is measured by statements such as: (1) You are treated with less courtesy than other people, (2) You are treated with less respect than other people, (3) You receive poorer service than other people at restaurants or stores, (4) People act as if they think you are not smart, (5) People act as if they are afraid of you, (6) People act as if they think you are dishonest, (7) People act as if you are not as good as they are, (8) You are called names or insulted, and (9) You are threatened or harassed. The items were taken from the Detroit Area Study (DAS) (Williams, Yu et al., 1997), and the scales have been used in mental health research (Finch et al., 2002; Mays & Cochran, 2001). We reverse-coded the response categories such that higher scores would reflect a greater frequency of perceived discrimination. The internal consistencies are high (Cronbach's a = 0.88 and a = 0.92, respectively).

In assessing visiting family abroad difficulties, respondents were asked to rate their answers from relatives abroad (1) to Very difficult (5). Years in the U.S. is an ordinal variable, with responses ranging from Less than five years (1) to more than 20 years (4). The U.S. region of residence, which initially consisted of four categories, (1) West, (2) East, (3) North, and (4) South, was transformed into four dichotomous variables corresponding to the four regions in the U.S. Contentment with the decision to move to the U.S. is represented by the dichotomous question, Would you decide to move to the U.S.? The answers include (1) Yes and (0) No.

Development context, the second segment of the FSM's external context, consists of the following variables: Age, continuous variables with respondents ranging from 18–97 years old; Age at immigration, a categorical variable where participants were asked, How old were you when you first came to this country? Moreover, whose answer categories included (1) less than 12 years, (2) 13 to 17 years, (3) 18 to 34 years, and (4) older than 34, English skills represented with questions such as: (1) How well do you speak in English? (2) How well do you read in English? and (3) How well do you write in English? The answers range from 1 – Poor to 4, Excellent. The internal consistency is very high (Cronbach's a = 0.93). Other variables of development context include education, an ordinal variable coded as (1) 0–11, (2) 12 years of education, (3) 13–16 years, and (4) more than 16 years of education; and marital status, transformed into three dichotomous variables representing the following categories, (1) married/cohabiting, (2) divorced/separated/widowed, or (3) never married.

Financial context. The third segment of the FSM's external context consists of financial constraints, an ordinal variable represented by the question, Rate your difficulty in meeting the monthly financial obligations and answers –ranging from (1) Not at all difficult to (4) very difficult; employment, a dichotomous variable coded as (0) not employed and (1) fully employed; and the continuous variable household income, referred to as income.

Gender-based roles and family-culture conflict represent the cultural context. The gender-based role is measured by one item: Which of the partners has the final say in household decisions? Research indicates that this construct can be used to indicate whether Latina women live in a household where a traditional gender-based role is in place (Baker, 2004). Family-culture conflict is represented by five items drawn from a subscale of the Hispanic Stress Inventory (HIS), which measure the cultural and intergenerational conflict between Latina immigrant women and their families (Cervantes et al., 1991). Participants were presented with items such as: (1) Because of the lack of family unity, you have felt lonely and isolated, (2) Your personal goals have been in conflict with your family, (3) Being close to family interfered with goals, (4) You argue with family over different customs. Each question about family-culture conflict has three potential response categories (1) Hardly Ever or Never, (2) Sometimes (3) Often. Higher scores were indicative of higher levels of conflict. The scale's internal consistency for this population is high (Cronbach's a = 0.81).

The fifth FSM context, the global context, is represented by the impact of 9/11. To assess the impact of 9/11, respondents were asked, As a result of the attacks, how much has your life been affected in the areas such as (1) losing one's job, (2) reduction in family income, (3) becoming more patriotic, (3) feeling safe, (4) unfair treatments due to race/appearance, (5) optimism about future, and (6) not coping well, in general. The answers ranged from a lot (1) to none (4). All items were reverse coded so that higher scores corresponded to higher levels of 9/11 impact. The internal consistency among these items is high (Cronbach's a = .74).

The cultural value of familismo and religiosity represent FSM's Internal Context. Familismo incorporates opinions of shared family, cultural values, and a general orientation toward family. The current study incorporates opinions of shared familial, cultural values, a general orientation toward family, family cohesion, and the willingness of family members to spend time with each other. The scale has been used frequently with people of Latin origin (Felix-Ortiz et al., 1994). It is measured by asking adults to rate their level of agreement with statements such as (1) Family members respect each other, (2) The family shares values, (3) Things work well as a family, (4) The family trusts and confides in each other, and (5) Family is loyal to family. Possible scores ranged from 10–40. All items were reverse-coded so that higher scores correspond to higher family cohesion levels. The scale's internal consistency is high (Cronbach's a = 0.80). Religiosity was studied using a question about church attendance, which probed the respondent about how frequently they attend religious services. Response categories ranged from (1) Often to (4) Never. Responses were reverse-coded such that higher values reflected higher levels of religiosity.

Statistical methods

We used mediation path analysis in MPLUS (Muthen & Muthen, 2005) to estimate relationships between contextual factors, acculturative stress, and psychological distress among the subjects in this study. All ordinal variables with at least four levels are treated as continuous (Muthen & Muthen, 2005). Categorical variables were transformed into binary variables to facilitate the analysis, while the dichotomous variables were left in their original dichotomous form. Only those covariates based on theory (Berry, 1997) or literature related to acculturative stress were entered into the model. All regression assumptions were assessed, such as linearity, homoscedasticity, and multicollinearity. Before entering various variables into models, two bivariate statistical tools were first used: correlations and analysis of variance. An analysis of the correlation involved an examination of the Pearson correlation to check for statistical significance of covariates and the two dependent variables. Only those contextual factors determined to have a significant relationship with acculturative stress and psychological distress were kept in the analysis. For Latina immigrants combined, these variables included decision-making power, perceived daily and racial discrimination, years in the U.S., 9/11 impact, visiting family abroad difficulties, financial constraints and level of income, age at immigration, age, contentment with the decision to move to the U.S., and education level, family-culture conflict, English skills, religiosity, familismo, and U.S. region of residence. Non-significant contextual factors included marital status. For Cuban-born women, statistically significant variables included contentment with the decision to move to the U.S., age at immigration, visiting family abroad difficulties, financial constraints, years in the U.S. English skills, perceived racial discrimination, family-culture conflict, familismo, employment, and age.

The mean substitution was performed for measures where participants had at least 80% complete data. For the measures with remaining missing values after mean substitution was completed (acculturative stress, familismo, and family conflict), and for English language proficiency, the Markov Chain Monte Carlo (MCMC) multiple imputation procedure was performed to correct the missing values. Five imputations, Stress, Family, and Mental Health, were generated for measures with missing data. The values from the imputations were then aggregated to create a final estimate of the missing values upon which the final analyses were based.

Specification search (Schumacker & Lomax, 2004) permitted the search for a better-fitting model, while a Modification Index (MI) informed our inclusion of specific parameters. MPLUS automatically calculated the indirect effects of covariates estimated in this study. Comparative Fit Index (CF), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Residual (SRMR) were used to assess the fit of the models. The maximum likelihood method (MLR), an estimator robust to non-normality, was employed. Standard errors estimated through MLR are very close to those produced through "bootstrap" methods; nonetheless, all the estimated baseline models were cross-validated using the holdover cross-validation technique.

Interactions between the various contexts in predicting acculturative stress were estimated using Stata's fitting software. Before testing for interactions, continuous variables and the ordinal variables were treated as continuous and mean-centered, and categorical variables were transformed into dichotomous variables to avoid collinearity. No interactions were significant among Cuban-born women.

Sample Characteristics. The descriptive statistics represented in Table 1 reveal several differences between Latina immigrants combined and Cuban-born Latinas. The noticeable differences between the two groups include marital status (71.2% of Cuban-born women report being married vs. 62.2% of Latinas in general), U.S. region of residence (92% of Cuban-born women live in the South vs. 54.5% of Latinas in the West), age at time of immigration (Cuban-born women generally entered the U.S. at an older age [40.9% older than 35 years of age] compared with other Latina immigrants who entered the U.S. between the ages of 18–34%), employment (Latina immigrant women were more likely to be working full time [58.7%, compared with 34.2% for Cuban-born women]), education (more Cuban-born women [22.22%] had a college degree vs. 12.8% of Latina immigrants combined), household decision-making power (more Cuban-born Latinas [15.5%] were likely to report having a say in all final household decisions vs. 8.3% of Latina immigrants combined), and visiting family abroad difficulties (56.1% of Cuban-born women reported that visiting the family back home was very difficult compared to 42% for Latina immigrants). Substantially more Cuban-born women report it to be very difficult to meet their monthly financial obligations (56.1% vs. 42.0%)

Compared to Latina immigrants combined, Cuban-born Latinas report lower levels of acculturative stress (M = 9.63 vs. M = 9.97) and psychological distress (M = 11.80 vs. M = 11.20 for Latina immigrants combined), are older (M = 52.75 vs. M = 45.15 for Latina immigrants combined), have a less family-culture conflict (M = 4.97 vs. M = 5.11 for Latina immigrants combined), report higher values of familismo (M = 38.01 vs. M = 36.60 for Latina immigrants combined), perceive less racial and daily discrimination (M = 4.57 vs. M = 5.23) and (M = 12.15 vs. M = 13.61) respectively, and have stronger English skills (M = 5.60 vs. M = 5.51 for Latina immigrants combined). Cuban-born Latinas were also reported to have been impacted more by the 9/11 incident (M = 13.18 vs. M = 12.64 for Latina immigrants combined)

Cuban-born women, contextual factors, acculturative stress, and psychological distress. We found support for the hypothesis (a) different contexts influence acculturative stress and psychological distress. English skills (b = − 0.33; p = 0.00), religiosity (b = 0.38; p = 0.04), visiting family abroad difficulties (b = 0.28; p = 0.00), perceived racial discrimination (b = 0.26; p = 0.00), years in the U.S. (b = -0.22; p = 0.00), contentment with the decision to move to U.S. (b = − 0.15, p = 0.00), and age at immigration (b = 0.18; p = 0.04) impacted acculturative stress of Cuban-born women. In contrast, age (b = 0.17; p = 0.00) and family-culture conflict (b = 0.28; p = − 0.00) impacted psychological distress. There was a relationship between acculturative stress and psychological distress (b = 0.15; p = 0.0), but acculturative stress had the smallest coefficient (Table 2).

Compared to their counterparts, Cuban-born women who reported contentment with the decision to move to the U.S. were likely to report less acculturative stress. Stronger English skills were associated with lower reported acculturative stress; higher reports of religiosity, visiting family abroad difficulties, perceived racial discrimination, and age at immigration were associated with higher reported acculturative stress.

Psychological distress, family-culture conflict, and age were associated with higher psychological distress.

Latina immigrants combined contextual factors, acculturative stress, and psychological distress. The following contexts impacted acculturative stress of Latina immigrants combined: English skills (b = 0.32; p = 0.00), visiting family abroad difficulties (b = 0.22; p = 0.00), perceived racial discrimination (b = 0.22; p = 0.00), years in the U.S. (b = -0.15; p = 0.04), family-culture conflict (b = 0.12; p = 0.00), age (b = 0.12; p = 0.00), and religiosity (b = 0.11; p = 0.00) (Table 2).

The following contexts impacted their psychological distress: age (b = 0.22; p = 0.00), perceived daily discrimination (b = 0.21; p = 0.00), income (b = -0.15; p = 0.00), familismo (b = -0.13; p = 0.04), acculturative stress (b = 0.12; p = 0.04), and contentment with decision to move to the U.S. (b = -0.10; p = 0.00) (Table 2).

Among Latina immigrants combined, greater reported English skills, length of stay in the U.S., and age was associated with lower reported acculturative stress. On the contrary, greater reported visiting family abroad difficulties, perceived racial discrimination, family-culture conflict, and religiosity were associated with greater reported acculturative stress. Regarding psychological distress, greater reported age, perceived daily discrimination, and acculturative stress were associated with more significant reported psychological distress. On the contrary, higher reported income and traditional beliefs of familismo were associated with lower reported psychological distress. Compared to their counterparts, Latina immigrants combined who reported contentment with the decision to move to the U.S. were more likely to report less psychological distress.

We found partial support for hypothesis (b) that contextual factors interact with each other in impacting acculturative stress levels. When controlling for English skills, visiting family abroad difficulties, perceived racial discrimination, family-culture conflict, age, religiosity, age at immigration, and years in the U.S. interacted with perceived racial discrimination to affect acculturative stress. As demonstrated in Fig. 3, the longer Latina immigrants combined lived in the U.S., the less impact the perceived racial discrimination had on their reported acculturative stress levels (Fig. 3).

Cuban-born women and Latina immigrants combined. The results reveal differences between the two groups of women and their experiences with acculturative stress and psychological distress, thus supporting hypothesis (c). Contrary to Latina immigrants combined, six vs. eight contextual factors impacted acculturative stress of Cuban-born women (i.e., English skills, visiting family abroad difficulties, perceived racial discrimination, years in the U.S., and contentment with the decision to move to the U.S.). Only three contextual factors impacted the psychological distress of Cuban-born women, vs. six for all Latina immigrants combined (i.e., family-culture conflict, age, and acculturative stress). The interactive effect among contextual factors was significant only for Latina immigrants combined (Fig. 3).

Research implications. Consistent with existing research (Bekteshi et al., 2018; Bekteshi & Van Hook, 2014; Torres et al., 2012), our study demonstrates that contexts predicting psychological distress are different from those predicting acculturative stress, supporting FSM (Boss, 2002) premise that acculturative stress and psychological distress should be studied as two separate concepts. The fact that acculturative stress contributes to psychological distress among all Latinas in this study suggests a need to further explore the link between acculturative stress and other symptoms of poor mental health while controlling for the impact of other contextual factors. Several contextual factors have different dimensions ( i.e., family-culture conflict, familismo, perceived racial discrimination), each of which may influence acculturative stress and psychological distress differently. These concepts should be further investigated.

The fact that contexts impacting acculturative stress and psychological distress among Cuban-born women were different from those of Latina immigrants combined warrants further investigation of the differences between these two groups. Age and family-culture conflict predicted more psychological distress among Cuban-born women than acculturative stress. Future research should examine factors beyond acculturative stress predisposing older Cuban women to psychological distress (e.g., poverty and lack of social and family support) (Ramos & White, 2010). Our results show that family-culture conflict challenges all Latino groups as they integrate into the new country (Szapoznik et al., 1980; Szapocznik et al., 1988). Since a high level of acculturation is linked to lower acculturative stress, effective acculturation strategies (e.g., biculturalism and multiculturalism) should be explored and promoted to buffer families' well-being from the negative impact of family-culture conflict. This is especially true, given that research indicates that family support and harmonious family relations are consistently linked with positive mental health among Latinas (Campos et al., 2007; Easter et al. et al., 2007; Bonnin & Brown, 2002).

Social discrimination toward Latinos in the U.S. has increased in recent years, paralleling the concern regarding the growth of undocumented Latino immigrants. This study indicates that although some Cuban women may benefit from the proximity of other Cubans by living in ethnic enclaves such as Little Havana in Miami, discrimination continues to be a concern that contributes to their acculturative stress (Bekteshi et al., 2014). Future studies should examine the impact of the year of entry into the U.S. and the relationship between discrimination and mental health among Cuban immigrant women. Linking the wave of Cuban immigration and the support available from the host society and the Cuban enclave with their mental health has been consistently supported (e.g., Van Hook, 2014).

Practice and Policy Implications. Results of this study help justify the need for long-term mental health solutions, which could be facilitated by advocating on behalf of socially-responsive relationships between Cuba and the U.S. Cuban-born women continued to report visiting family abroad difficulties at the time of data collection, despite the recent government policies that have made it more possible for them to travel home. Effective integration interventions should incorporate specific contributors to psychological distress (e.g., issues with family in the U.S. and Cuba and experiences with discrimination) rather than only those about acculturation.

As the study results demonstrate, perceived racial discrimination continues to be present in the lives of Cuban women, indicating a need for practitioners to acknowledge it as a significant aspect of any treatment plan. An emphasis should be placed on exploring the perception of discrimination by this community for effective and more culturally-sensitive services. Prior experiences of discrimination may make clients hesitant to reach out for help. Although many Cuban-born women might be documented immigrants and thus eligible for available social and health services, current social movements that create distrust among Latinos can influence their experience with health services. Any effective outreach effort should be embedded in awareness of such concerns. Given the importance of various religious groups in the lives of many Latinos (Sanchez et al., 2012), the presence of a religious community in outreach services and other programs targeting Cuban immigrant women might facilitate rapport building and trust, two essential components in any service plan.

As in prior studies (Ramos 2005, 2012), we found that a lack of English language skills contributed to acculturative stress among all participants. While services must bridge the language issue by having staff with culturally relevant language skills, working within the community to create opportunities for people to build their English language skills is essential for reducing acculturative stress. Such efforts may be paired with programs that build a sense of community and help find ways to address discrimination while validating one's cultural identity, as well as with programs that facilitate access to opportunities that build employment skills.

The family conflict increased psychological distress for Cuban-born women. Potential sources of conflict may include different levels of acculturation by family members, changes in gender roles, and differing responses to new cultural expectations (Burgos, 2002). Latinas in previous studies requested services to help family members improve their communication, especially across generations (Ayon, 2014). Such services could help families negotiate ongoing changes, identify effective response mechanisms, and reduce conflict.

Limitations. Given the cross-sectional nature of the data, the temporal ordering among the constructs in all the estimated models is based exclusively on theoretical premises and literature review. Consequently, even though the models have been cross-validated to ensure the estimated parameters are stable, it is possible to delineate divergent casual sequences among the contextual constructs and the two outcome variables in this study. Furthermore, NLAAS was not originally designed to test the hypothesis of this study, and the fact that some of the variables are used to assess contexts not initially designed for the study, i.e., gender-based roles, could be considered a stretch. The gender-based roles variable could be disputed, particularly given that men and women tend to have differential power levels across household domains. For example, one might have the final say regarding expenses, while another may have the final word regarding children and other family matters.

Furthermore, NLAAS was conducted more than ten years ago. The Latino population in the U.S. has undergone several changes since that time that the data may not capture. For example, the Latino population has grown substantially, and attitudes toward Latinos in the U.S. may have changed, especially given the current immigration debates. These demographic and sociopolitical trends may affect how much Latinos experience discrimination.

Another limitation is that this study is limited mainly to Cubans living in Florida; the experiences of Cubans in other parts of the U.S. might be different. In the current sample, most Cubans (92%) reported living in Florida; however, only about 70% of all Cubans in the U.S. reside in Florida.

Another data-driven limitation is an omitted variable bias: race. The Cuban population is diverse racially; white Cubans and Afro-Cubans might experience acculturative stress and psychological distress differently due in part to racially motivated discrimination.

Despite the limitations, this is the first study to examine the impact of numerous contextual factors on psychological distress among Cuban-born women in the U.S. NLAAS provides a representative sample of Cubans, and exploratory studies have proven very useful given the limited literature on the subject in order to motivate future, more focused research. Smaller and more concentrated studies should be undertaken to test the impact of the referenced contextual factors on various immigrant groups' acculturative stress and psychological distress. The comprehensive analysis provides the most thorough knowledge on the impact of environment, cultural values, and acculturation strategies on the psychological distress of Cuban-born women in the U.S.

Competing interests: The authors declare no competing interests.

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Table 1 Descriptive Statics of Contextual Factors among Latinas and Latinas Born in Cuba

Contexts	Latina immigrants combined	`Cuban-born
	N = 639	N = 264
Marital Status (%)
Married/Cohabiting	62.2	71.2
Divorced/Separated/ Widowed	23.9	17.0
Never Married	13.9	11.7
U.S Region of Residence (%)
Northeast	16.3	8.0
Midwest	5.6
South	23.6	92.0
West	54.5
Age at Immigration (%)
Less than 12 years	24.7	18.2
12–17 years	12.7	6.8
18–34	33.7	33.7
35+	21.6	40.9
Religious Activities (% freq)
Often	41.8	45.5
Sometimes	25.4	11.0
Rarely	13.3	23.9
Never	19.1	19.7
Education (%)
0–11 years	49.9	33.7
12 years	21.3	25.1
13–15 years	15.6	19.0
>16 years	12.8	22.22
Employment (%)
Full employed	58.7	34.2
Not employed	41.3	65.8
Happy with the U.S. Move (%)
Yes	92.7	96.6
No	6.1	3.4
Years in the U.S. (%)
Born in the U.S.	0	0
Less than 5	7.0	20.1
5–10 years	13.3	10.06
11–20 years	21.6	11.0
20 +	49.1	58.0
Has Final Say in Decision (%)
Always	8.3	15.5
Sometimes	55.3	34.1
Never	31.5	9.1
Contexts	Latina immigrants combined	Cuban-born
Visiting Family Abroad Difficulties (%)	N = 639	N = 264
No relatives abroad	4.60	8.3
Not at all difficult	21.7	11.4
Not very difficult	10.7	7.6
Somewhat difficult	20.9	16.3
Very difficult	42.0	56.1
Difficulties in making monthly bills/ Financial constraints (%)
Not at all difficult	15.0	15.2
Somewhat difficult	26.3	24.6
Not very difficult Very difficult	40.8 42.0	33.0 56.1

Continuous Variables Combined group of Latinas Cuban-born women
	M	SD	Range M		SD	Range
Acculturative stress	9.97	1.93	8–16	9.63	1.56	8–14
Psychological distress	11.29	5.61	7–35	11.80	6.25	7–35
Age	45.15	16.61	18–79	52.75	16.15	18–97
Family-culture Conflict	5.11	1.62	4–12	4.97	1.64	4–12
Familismo	36.69	4.86	10–40	38.01	4.04	13–40
Racial Discrim	5.23	2.38	3–12	4.57	2.11	3–12
Daily Discrim	13.61	5.9	9–42	12.15	5.04	3–12
English Skills	5.51	3.16	3–12	5.69	3.34	3–12
9–11 impact	12.64	4.16	7–28	13.18	3.71	7–26

Table 2. Relationships between contextual factors, acculturative stress and psychological distress: Latina immigrants combined, vs. Cuban-born women

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Contextual approach to immigration challenges among Cuban women

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Introduction

Cuban-born women

Cuban Women and Acculturative Stress

Theoretical Framework: Family Stress Management Theory; Contextual Influence in Acculturative Stress (CIAS)

Methodology

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