Using Qualitative Methods for Revising Items in the Hispanic Stress Inventory

Abstract

Despite progress in the development of measures to assess psychosocial stress experiences in the general population, a lack of culturally informed assessment instruments exist to enable clinicians and researchers to detect and accurately diagnosis mental health concerns among Hispanics. The Hispanic Stress Inventory (HSI) was developed specifically for Hispanic adults, however, significant social and geopolitical changes over the past two decades have affected the types and intensity of stress experienced by Hispanics. Immigration related policy changes, for example, affect stress experiences among newer immigrants from Mexico and other Latin American countries in ways that items in the original HSI may no longer capture the full range of today’s stressors. Using expert interviews from Hispanic mental health experts and data gathered in 16 community-based focus groups at two distinct study sites, the goal of the current study was to identify new item content to include in a revised HSI. Using content analysis of all interview data, a total of 155 new stressor items and seven unique stress domains were generated. Content validity analysis using Kappa coefficient reveal high interrater validity for new HSI item content. Findings are described in depth, and recommendations for future research are identified.

Keywords

Hispanic Stress Inventory immigration stress health care stress cultural conflict stress economic and occupational stress adults

There have been numerous advances in mental health assessment and diagnostic testing for adults (Hunsley & Mash, 2005). Much of this development and research has aimed at specifying psychological symptomatology and distinct emotional disorders such as depression (Beck, 1961), anxiety (Antony & Rowa, 2005), personality disorders (Costa & McCrae, 2006), trauma (Kubany, 2004), posttraumatic stress disorder (Briere, 2004), intimate partner violence (Straus, 1979, 1990), stress (Nowack, 1999), couple distress (Snyder, Heyman, & Haynes, 2005), and parenting stress (Gerard, 2005) among others.

Despite these developments, a lack of culturally informed assessment instruments exist to facilitate detection and accurate diagnosis in diverse cultural and linguistic groups. In a recent review of literature on cross cultural measurement issues, for example, Suzuki, Ponteroto, and Meller (2007) identify issues in culturally appropriate assessment, including ethical concerns, the importance of community norms testing, and multicultural considerations in the delivery (i.e., use of technology) of assessment instruments.

In terms of psychological measures for Hispanic mental health needs (Malgady & Zayas, 2001; Cervantes, Cordova, Fisher, & Kilp, 2008), research has found that in response to stressful events Hispanics may manifest symptoms that are culturally bound (i.e., Culture Bound Syndromes) such as ataque de nervios (Guarnaccia, Canino, Rubio-Stipec, & Bravo, 1993; Guarnaccia, Lewis-Fernandez, & Rivera-Marano, 2003). The National Institute on Mental Health (NIMH) convened a panel of researchers to prioritize the mental health needs of Hispanics, finding that the development of culturally relevant diagnostic instruments, enhanced quality of care, culturally appropriate services, and increased access to health care are areas of research potential (Vega et al., 2007).

Currently Available Assessment Instruments for Hispanics

Some culturally based measurement instruments do exist for Hispanics. For example, the Acculturation Rating Scale for Mexican Americans-II (ARSMA-II; Cuellar, Arnold, & Maldonado, 1995) was developed as a multidimensional assessment to measure levels of acculturation in Mexican Americans and is widely used. Numerous critiques and limitations of the original ARSMA (Cuellar, Harris, & Jasso, 1980) prompted the development of a second version, which proved to have more utility in measuring acculturation (Cuellar et al., 1995). Rodriguez and colleagues (2002) created the Multidimensional Acculturative Stress Inventory (MASI; Rodriguez, Myers, Mira, Flores, & Garcia-Hernandez, 2002). Although the MASI may prove useful in future studies, similar to the ARSMA-II, it is limited to a Mexican origin population and only measures acculturative stress. Recently, Butcher and colleagues (2007) also revised the Minnesota Multiphasic Personality Inventory (MMPI-2) for use with Hispanic clients.

Another instrument developed specifically for Hispanic adults is the Hispanic Stress Inventory (HSI; Cervantes, Padilla, & Salgado de Synder, 1990, 1991). The HSI has been previously used in studies to examine psychosocial stress in Hispanic adults (e.g., Alva & de Los Reyes, 1999; Dwight-Johnson, Ell, & Lee, 2005; Finch, Hummer, Kolody, & Vega, 2001; Madrid, MacMurray, Lee, Anderson, & Comings, 2001; Salgado de Snyder, Cervantes, & Padilla, 1990; Thoman & Suris, 2004; Vega et al., 1998). Most recently, the HSI has been used to study the relationship between psychosocial stress and neuroticism (Mangold, Veraza, Kinkler, & Kinney, 2007), violence risk and outcomes with Mexican American Hispanics (Cervantes, Duenas, Valdez, & Kaplan, 2006), family acculturation and Hispanic substance abuse (Martinez, 2006), and the interaction between country of origin, gender roles, and acculturation on intimate partner violence (Harris, Firestone, & Vega, 2005). The original version of the HSI proved to be useful in detecting stress events in a variety of life domains, including immigration stress, parental stress, economic/occupational stress, family/cultural conflict and marital stress.

Since the development of the HSI over 20 years ago, there have been significant sociodemographic and sociopolitical shifts within the Hispanic population that affect stress in this community. Dramatic population increases, immigration concerns, public health epidemics, and an increased health disparity burden have all affected individuals and families and have significantly altered the nature, frequency, and intensity of culturally based acute and chronic stress events in this population group. In the last decade, the public policy discourse surrounding undocumented and monolingual Spanish-speaking immigrants have had a profound effect on the mental health of individuals, families, and communities. Policies and anti-immigrant attitudes have led to family separation and family reunification concerns that further dismantle the psychological and social fabric of many Hispanic families (McGuire & Martin, 2007). Furthermore, constant negative references and images toward one’s own ethnic or cultural group have had a profound impact on sense of self, self-image, and developmental trajectories (Cordova & Cervantes, 2010), and this chronic stress can lead to a myriad of risk behaviors (Hawkins, Catalano, & Miller, 1992).

Given the need to improve the depth and breadth of the original HSI item content and subscales, the purpose of this research was to conduct community-based focus groups to confirm the HSI constructs, while at the same time identifying new areas of stress exposure and experiences among a diverse group of Hispanic/Latino adults in two distinct geographic regions within the United States. The goal of the current study was to explore contemporary culturally based stressors and identify new item content in a restandardization study of the HSI (called the HSI-2) to benefit health care providers and researchers in more accurate assessment and treatment of negative behavioral health outcomes among Hispanic adults.

Method

A qualitative study design using expert interviews and community-based focus group methods were used to verify and adapt conceptual stress categories in the HSI. Initially, a number of key theoretical issues related to Hispanic adult stress were identified in a literature search and through interviews with recognized expert researchers in the field of Hispanic mental health and acculturation stress. The expansion of core theoretical concepts related to psychosocial stressors from the constructs in the original HSI development study was an important starting point for the current study.

Expert panel

Three well-published experts in Hispanic mental health (see, for example, Cortés et al., 2007; Santisteban, Vega, & Suarez-Morales, 2006) were engaged in the initial restandardization process. All experts had also been directly involved in similar instrument development work with the authors (Cervantes et al., 2008; Cervantes Fisher, Córdova & Napper, 2011) and each continues to contribute to the behavioral science knowledge base on culturally appropriate assessment and treatment approaches and language translation techniques. The three experts were initially sent a package of information to prepare them for the interview process. In the preinterview package, the expert panelists were instructed to (1) review the original HSI content and study procedures (Cervantes et al., 1991); (2) review the definitions of each original stressor domain; (3) review all original content within each stress domain; (4) provide comments and critique on the original definitions and item content; (5) provide other information on contemporary stressors that Hispanics experience in the United States; and (6) provide additional themes and probes for the development of a focus group interview protocol.

Each expert was then interviewed using a semistructured protocol. The purpose of the interview was to clarify their responses in the initial information gathering phase, modify the conceptual stress domains identified that were culture-specific to Hispanic adults, to explore other contemporary stressor domains that may be discussed in the community-based focus groups, and to finalize the focus group interview protocol. The interview findings resulted in modified stress domains from the original HSI, including the separation of family stress and cultural conflict into separate domains, and the addition of a new domain of stress related to accessing health care. The final seven conceptual domains were Immigration Stress, Family Stress, Marital Stress, Cultural Conflict, Health care Stress, Parental, and Economic/Occupational Stress.

Community focus groups

Beyond the expert panel interviews, a second step in this research methodology involved the use of community-based focus groups with a large sample of Hispanic adults. The focus group interview guide consisted of seven sections corresponding to the modified stressor domains with an opening description of the domain, a list of open-ended questions about stressor experiences, and a series of specific probes related to the content. In each domain a probe concerning the chronicity of the specific experience was added (i.e., “of the problems you’ve talked about, what never went away or was the hardest to change?”).

Focus Group Recruitment

Focus group participants were recruited in collaboration with community-based organizations that have strong ties to Hispanic communities in both California and Massachusetts. This sampling frame had the advantage of including a more heterogeneous and diverse sample of Hispanics when compared with the original HSI development study sample that was based only in Southern California. Convenience sampling occurred in adult education centers, adult skills centers, homeless outreach facilities, and local behavioral health services clinics. Sampling in these two states helped to ensure that information about stress events were elicited that are relevant to a wide range of Hispanics from diverse cultural origins, both immigrant and nonimmigrant and racially diverse groups. The research team collaborated closely with site coordinators who acted as liaison in the target communities. Potential participants were identified by agency liaisons and given a choice to attend either a Spanish or English language group based on their own language preference.

Inclusion criteria for participation in the study included (1) Self-described Hispanic ethnic identity (including Caribbean, Puerto Rican, Cuban, Dominican, Central American, and Mexican backgrounds); (2) age 18 and older; and (3) willing to provide consent indicating their interesting in participating in the study. Exclusion criterion included (1) Self-described non-Hispanic ethnic identity; and (2) diagnosed acute mental health disorder such as acute psychosis, dementia, or active suicidal ideation.

Procedure

On the basis of the expert panel interviews and the existing literature, a semistructured, focus group interview guide was developed. This guide included general and open-ended questions within each of the stress domains identified by the expert panel as well as specific focused probes. The questions referred to stress event and appraisal experiences. For example, we expected that, based on differences in acculturation levels between parents and their children, chronic interpersonal relationship strain between parents and their children would be one of the adult domains identified by the expert panel. This domain was first explored in the group by raising a general question, “What are the most difficult things that Hispanic adult parents have to deal with?” The group was then asked to respond with specific information based on their personal experience (i.e., “What are the most difficult things you had to deal with in your relationship with your child?”).

Next, the group was asked how they responded to the elicited stressors. At least three different participant behavioral reports were elicited from each question. The aim was to collect situation-specific stress reactions and reduction behavioral reports rather than accounts of general reactivity and coping styles. Special attention was placed on immigration stress as experienced by immigrant adults and perceived by their nonimmigrant peers.

All data collection was completed in person, with a member of the research team present. Potential participants gathered in a reserved room in each data collection site where the focus groups were conducted. Participants were told the purpose of the study and were given consent forms. Those participants who provided consent were given a US$10 gift card and asked to complete a sociodemographic questionnaire that included measures of immigrant status (e.g., where born; how long in the United States, etc.). Two doctoral-level staff with extensive interviewing experience moderated the focus groups, which were audio-recorded for later transcription. In addition, a staff member took extensive notes while observing the group to enhance the quality of data collected.

Sample

A total of 16 focus groups consisting of 93 focus group participants were conducted, as shown below in Table 1. Focus group participants were selected from two sites with large Hispanic populations in southern California and the northeastern United States. A mixed stratified sampling strategy was designed to elicit information about stress events that are relevant to a wide range of Hispanic adults from diverse cultural origins, both immigrant and nonimmigrant.

Table 1.

Focus Groups

	Southern California	Northeastern United States
Men	3 groups (n = 21)	2 groups (n = 9)	5 groups (n = 30)
Women	3 groups (n = 12)	3 groups (n = 19)	6 groups (n = 31)
Mixed Gender	2 groups (n = 14)	3 groups (n = 18)	5 groups (n = 32)
TOTAL	47	46	16 groups (N = 93)

Data Analysis

First, all focus group interviews were transcribed in either English or Spanish. These transcripts were then analyzed by two PhD-level research staff including the PI. Analysis of data was completed using grounded theory and the constant comparison method with a triadic process of open, axial, and selective coding (Strauss & Corbin, 1998). Open coding consists of a line by line analysis to break down data into discrete parts or units of analysis, labeling different units as concepts, and analyzing the phenomena embedded in the data (LaRossa, 2005). Concepts were labeled using the words expressed by participants, a procedure known as in vivo coding (Strauss & Corbin, 1998).

Subsequent to open coding, categories were created to reach a higher level of conceptualization, a process referred to as axial coding. This process facilitates identification of relationships among categories based on their properties and dimensions. For example, the category “Occupational Stress” had variations in the type of stressors experienced (e.g., working under harsh conditions, not getting along with coworkers). Lastly, the final phase of the analysis consisted of selective coding (Strauss & Corbin). This process will consist of integrating a theoretical schema of the phenomena under study (i.e., stress domains). In other words, this step in the triadic process aims to select the main domains underlying the analysis that most accurately describes the participants’ experience (Fassinger 2005; LaRossa, 2005).

Two PhD-level researchers conducted the content analysis separately. Subsequently the two coders reviewed all extracted themes and reached consensus on these coded themes. These codes were then sorted into categories that produced emergent core themes (Lofland & Lofland, 1995; Strauss, 1987). The groups of core themes were further abstracted into stress item stems. These item stems were then used to write meaningful item statements that were related to the content utterances. Last, the two coders met to discuss codes and to reach consensus. This approach to the coding of focus group data is consistent with content analytic procedures (Krippendorff, 2004a and b) and resulted in the development of 187 new stressor items.

Results

Demographics

Table 2 below outlines the demographics of the focus group sample.

Table 2.

Participant Demographics

	N (%)
Language
Spanish	55 (59)
English	38 (41)
Gender
Male	48 (52)
Female	45 (48)
Age
Under 25	17 (19)
26-35 years old	17 (19)
36-55 years old	32 (35)
56 or older	24 (27)
Living situation
With spouse or partner	42 (47)
Children	30 (32)
Parent at home	44 (47)
Marital status
Single	30 (38)
Married	34 (44)
Separated	6 (8)
Widowed	2 (3)
Living with someone else	6 (8)
Have children	66 (71)
Language spoken in home
English	27 (29)
Spanish	59 (63)
Both English and Spanish	6 (6)
Hispanic subgroup
Mexican	53 (57)
Central American	7 (7)
South American	2 (2)
Puerto Rican	13 (14)
Other	18 (19)
Highest level of education
Less than high school	30 (35)
High school	26 (30)
Some college	20 (23)
Complete college or higher	10 (12)
Employment status
Employed	35 (38)
Unemployed, looking for work	9 (10)
Unemployed, not looking	24 (26)
Disabled	19 (21)
Retired	4 (5)
Household income per year
Under US$10,000	24 (30)
US$10,001-US$25,000	25 (31)
US$25,001-US$45,000	17 (21)
Above US$45,000	14 (18)

A descriptive analysis indicated that 51% of the focus group participants were recruited from Los Angeles and 49% from Boston. More males (52%) than females (48%) participated in the focus groups. The mean age of the sample was 41.76 (SD = 15.43) years, with a range of 18 to 67 years of age. A large portion of the sample (57%) reported the country of origin of their family to be Mexico, followed by Puerto Rico (14%). The “other” category (e.g., Cuban, Dominican) was named by 19%, which is representative of the U.S. Hispanic population. Fifty-eight percent of the participants were born outside the United States (58%), and primarily spoke Spanish (59%). The majority of respondents (71%) reported having children and many lived in multigenerational households with spouses or partners, children, and their own (or partners) parents. Furthermore, 38% of participants reported being employed either full- or part-time, followed by unemployed (36%), disabled (21%), and retired (5%). A total of 30% of participants who reported their income lived below poverty, with an annual household income of US$10,000 or less.

Stressor Domain and Item Descriptions

The focus group data resulted in the generation of 187 item statements capturing specific stress events within each a priori defined domain. After a comparison between the original HSI and the new item content, 22 items were eliminated. Those items removed were found to be nearly identical to the original HSI items or duplicated other new items. Table 3 shows an abbreviated version of the final 155 salient stressor experiences described by focus group participants, as organized into stressor domains.

Table 3.

Abbreviated HSI Stressor Experiences

Immigration Stress Items

1. My family was exposed to poverty

2. Not enough money for basic things

3. Left home country due to poverty

4. I did not have freedom in my home country

5. I lacked educational opportunities

6. I did not get good health care

7. Members of my family could not get good health care

8. I was without food or water coming to the United States

9. I was robbed coming to the United States

10. I was sexually assaulted coming to the United States

11. I was forced to pay a “coyote” to help me

12. I saw people die

13. I could not find a place to live

14. I saw gang violence

15. I could not afford to bring my family

16. I did not have the proper legal documents

17. I moved from a small town to the city

18. I was separated from my spouse

19. I was divorced due to immigration

20. I lost contact with family members

21. I could not afford to pay for basic living

22. Members of my family cannot communicate in public places

23. Children in my family had to translate

24. I could not make important changes in my marriage

25. I was called names and treated badly

26. I had difficulty adjusting to the legal system

27. I did not know about the tax system27

Cultural conflict stress items

28. I was harassed by police28

29. I had to accept poor housing conditions

30. I was not expected to go to college

31. I was treated “less than” other Americans

32. I could not communicate with others

33. I was treated like a slave

34. Lived in an overcrowded home

35. I did not have any independence

36. Had legal problems

37. I was arrested

38. I felt pressured to leave my home

39. I was discriminated against because of my customs

40. Difficulty adjusting to American customs

41. Members of my family had difficulty adjusting to American culture

42. I experienced discrimination

43. Education and training from my home country did not count

44. I had difficulty finding food

45. I lost my religious beliefs

46. My religious practices were in conflict

47. I felt pressured to put more emphasis on time

48. Family members left home 48

Health related stress items

49. Member of my family had a major health problem49

50. I had a major health problem

51. I did not have health insurance

52. I could not pay for my medical care

53. We did not have health insurance

54. Because of language differences, I did not get medical care

55. I was discriminated against in the hospital

56. I lacked information about health care

57. There are not enough health facilities

58. I did not have access to health care

59. Because of the lack of legal documentation, I could not get health care

60. I had to go to an emergency room

61. I had to wait for a long time

62. I had difficulty understanding and filling out forms

63. I could not get dental insurance

64. I could not take time off from work

65. No interpreter

66. I could not find a Hispanic doctor

67. I had no transportation

68. I had to use home remedies

69. I did not trust the medical staff

70. Members of my family were too proud

71. I did not get medical care because I did not want to appear weak

72. I needed mental health care

73. I could not pay for mental health care

74. I was forced to pay medical bills with a credit card

75. I did not understand my illness75

Parental stress items

76. My child is in a gang76

77. My child was harassed by gang members

78. Violence at my child’s school

79. Drugs sold at my child’s school

80. My child was discriminated against at school

81. I was discriminated against at my child’s school

82. Communication with my child’s teacher or principal

83. I could not help my child with homework

84. Teachers did not want him/her to use Spanish at home

85. I had problems communicating with my child

86. I had difficulty monitoring my child

87. Problems with discipline or setting rules for my child

88. My child was arrested

89. My child broke our rules

90. I had arguments with my child about cultural values

91. My spouse was reported to the authorities about spanking

92. I was reported to the authorities about spanking

93. My child threatened to call the police

84. I had difficulties motivating my child

95. My child quit school

96. I had problems discussing sexual topics

97. I had difficulties talking about drugs

98. I had arguments with my child about buying things

99. Arguments with my child about sleeping at a friend’s home

100. Because I am a single parent, difficult for me to monitor my child

101. My son or daughter became sexually active

102. My child uses the phone or text messages too much

103. My child spends too much time on the computer103

Marital stress items

104. Domestic violence104

105. Infidelity

106. There is lack of trust

107. Separated from my spouse

108. Talked about divorce

109. My spouse had a drug abuse problem

110. Disagreed about having children

111. Disagreed on where we should live

112. Disagreed about going back to our home country

113. My spouse had a mental health problem

114. My spouse lost his/her job

115. Acted too Machista

116. Disagreed about choosing our friends

117. Taking care of my spouse’s parents

118. My spouse had a serious medical problem

119. There was a lack of respect

120. Have different personalities120

Family stress items

121. Member of my family used drugs121

122. Alcohol abuse happened in my family

123. No positive male figure

124. Members of my family were divorced

125. I had to take care of relatives

126. Difficult to decide how to care for elderly parents

127. It was difficult keeping the family together

128. I lost my job

129. I cannot communicate in Spanish

130. Members of my family cannot agree on what food to eat

131. Family experienced discrimination

132. Family experienced loss in income

133. Members of my family lost their home

134. I lost my home

135. My children who are 18 or older do not help with family finances

136. Men in our family were too macho

Economic and occupational stress items

137. Because I did not have a social security number, I could not apply for or find good employment

138. Because I did not have a driver’s license, it was difficult to get to and from work

139. I was overworked at my job

140. I was discriminated against at my job

141. I was unemployed or lost my job

142. I could not find a job

143. Not knowing English made it difficult to find a job

144. I could not get student loans

145. I could not get a loan for a home

146. I did not understand the American system of credit

147. People with less skills or education than me have better jobs

148. I did not have the money to attend college

149. Because I had to earn money, I could not go further in school

150. Family health problems forced me to leave my work

151. I did not understand how to enroll in college

152. I was given the lowest position at work

153. I had problems paying the basic bills

154. I had no family support to continue my education

155. I could not do the work I was trained for in my home country

The largest number of newly generated stress items was for the domain “Parent Stress” (28 items), followed by “Access to Health care Stress” (27 items), “Immigration Stress” (27 items), “Cultural Conflict Stress” (21 items), “Occupational and Economic Stress” (19 items), “Marital Stress” (17 items), and, lastly, “Family Stress” (16 items).

Access to health care stress

Within the health domain, lack of affordable insurance and lack of insurance options for undocumented individuals were common themes. In addition, participants expressed language barriers in a medical context, challenges with utilizing an interpreter, mistrust of doctors and medical institutions, transportation challenges, lacking dental insurance, and lack of information with respect to mental health care as significant stressors in their lives. New item content developed under this theme included stress in being “unable to pay for health care to cover my illnesses” and “discrimination at the hospital or health clinic due to being Hispanic” or “due to language differences.” Health care stress was uniquely tied to other stress experiences, such as economic stress. For example, participants noted that the nature of their jobs either did not offer health insurance, or that lacking a regular job meant going without.

Immigration stress

Participants in this study indicated challenges and stressors with socioeconomics and poverty, lacking political freedom in their home country, emigrating to the United States. (e.g., violence), family separation, language barriers, and discrimination. A large number of participants reported experiencing poverty in their home country. As one participant stated, the “overall quality of my life was bad in my home country.” The process of immigrating to the United States was particularly stressful, with participants discussing the stress in paying a “coyote” to help them cross the border, seeing people die during the crossing, and often being unable to bring their families with them when entering the United States. An additional stressor was the absence of proper legal documents to be in the United States.

Parent stress

Hispanic adult parents in this study shared the ways in which neighborhood gangs, violence at their child’s school, children being exposed to drugs, discrimination, language barriers in their child’s school context, inability to monitor children because of work demands, acculturation differences between parent and child, and discussing challenging topics with children and adolescents (e.g., drugs and sex), as significant and stressful challenges to their parenting efforts. Parent participants described being unable to communicate with their children’s teacher or principal, and lacking the ability to assist children with their homework. Participants described that many teachers “did not speak Spanish” and that language differences even meant “problems in communicating with my own child.” Also differences in disciplinary practices (e.g., spanking) were mentioned as problematic because of child abuse policy in this country.

Cultural conflict stress

Participants in this study shared the ways in which racial profiling from police authorities, discrimination, poor housing conditions, lower educational expectations because of their minority status, language barriers and acculturation challenges all serve as significant stressors. Several participants noted being “harassed by police because of being Hispanic,” having to accept “poorer housing conditions because I am Hispanic” and even being “treated like a slave because I am Hispanic.” Participants also reported that celebrating their customs and cultural events often led to discrimination and that adjusting to American cultural and customs was difficult for both them and their families.

Marital stress

Within the marital context, participants expressed intimate partner violence, substance abuse, partner separation, machismo, economic challenges, and deciding where to reside (home country vs. United States), as significant stressors in their lives. Some participants described separation resulting in infidelity or a lack of trust, and increasing talk of divorce. Furthermore, some participants described “taking care of my spouse’s parents” and “disagreements about choosing friends” and disagreements “about going back to home country” as significant stressor experiences.

Family stress

Findings in this study highlight two significant stressors in the family context. Participants highlighted the ways in which alcohol and drug abuse create problems, and how caring of extended family serve as significant stressors in the lives of participants. With regard to the use of substances, participants described “alcohol abuse in the family” and “members of my family using drugs” as stressors. In caring for family members, participants described difficulty in the “family deciding how to care for older parents” and an inability to “communicate in Spanish with older family members.” Other stressors included loss of income and loss of the family home. Lessor problems included disagreements were about which foods to eat, with changes in the cultural experience of the U.S. impacting these decisions.

Occupational and economic stress

Participants in this study described the ways in which undocumented status, discrimination in the workplace, unemployment or loss of job, and difficulty paying bills resulted in stress. In addition, the lack of financial resources for higher education including student loans also served as significant stressors in the lives of participants. Participants described the impact that “not having a social security card had on applying or finding good employment” and that “lacking a drivers license meant difficulty getting to and from work.” Lacking documentation also resulted in other negative outcomes including being “overworked at my job,” “underpaid at my job,” “discriminated against at my job,” and inability to obtain loans. Again, the language barrier was described as causing “discrimination,” “unemployment,” and “difficulty in finding/keeping a job.” Discrimination was often described at work, including the experience of “people with less skills or education than me having better jobs.”

Content validity analysis

After the 155 items were identified, they were sent to two additional clinical experts in Hispanic mental health (separate from the original expert panel) to assign each item into one of the seven conceptual stress domains and assess interrater reliability. The experts were instructed to assign the number of the one domain they thought the item best fit under. Cohen’s kappa index of interrater agreement (Cohen, 1960) was used to measure the extent of consensus. This statistic is considered to be an improvement over using percentage agreement to evaluate interrater consensus because it considers chance in the calculation. Kappa is the proportion of agreements after chance agreement has been excluded.

The Kappa index coefficient (k = .55) was statistically significant (p < .001). In addition, Pearson correlation analysis indicated a significant correlation between Expert 1 and 2 (.654; p < .01) in terms of item ratings across all domains for the 155 new HSI-2 items. While higher Kappa and Pearson estimates were desirable, at this stage in revising the HSI, our goal was to have general consensus on item placement within any one subcategory, knowing that further psychometric testing, including factor analysis, would yield a more refined set of categories and item placement within categories (factors) as in previous work with the HSI and HSI-A. On the basis of the Kappa and Pearson correlation analysis of the two experts, all of the scale items were retained. As this set of items was generated from Hispanic adults themselves in a first phase of scale development, the researchers concluded that the Kappa was sufficient to not warrant further item exclusion.

Discussion

The purpose of this study was to learn about contemporary stressful life events related to being Hispanic in the United States, and to use this new information in the development of additional item content for a revised Hispanic Stress Inventory (HSI-2). Since the original HSI was developed, changes in the United States for Hispanics has had a significant effect on both physical and behavioral health outcomes (Cordova & Cervantes, 2011), with negative feelings toward Hispanics (McGuire & Martin, 2007) and high rates of poverty (Cervantes et al., 2011) increasing since the original instrument was developed.

The HSI was developed as an instrument for assessing culturally based stressors, and we were particularly interested in how these sociopolitical shifts over the last 20 years had affected stress and health for Hispanics today. As hypothesized, there were a number of new and salient life stressor events that were not identified in the original instrument. Through this study we also refined specific item content within the preexisting domain categories to be added in a revised HSI.

Notably, while other domains of Hispanic psychosocial stress and specific stress events were enhanced and expanded upon, stressors related specifically to access to health care was one global dimension of stress previously not identified through psychometric item analysis or factor analysis conducted in the original series of HSI development studies. Participants described barriers to accessing and receiving health care, including the lack of trust they had for medical providers given cultural and language differences. This new conceptual stress domain may have emerged more prominently given the current sociopolitical climate of health care (i.e., Health Care Reform). The appearance of health care stress is an example of why culturally based instruments should be regularly revisited for new population needs.

Findings from this qualitative study also suggest that the process of immigrating to the United States has also become more dangerous, as described by study participants. New stressor experiences within Immigration Stress described trauma from experiencing violence (including personally seeing murders) while crossing the border, increased scrutiny and discrimination from U.S. persons, and stress around paying a “coyote” to assist in making the dangerous trip into the United States.

Parenting was described as an additional source of stress, with new items around drug use and sexual behavior added to the HSI as well as experiences of violence at school and from neighborhood gangs. The increased stress of being Hispanic, along with new scrutiny toward Hispanics became clear within the Cultural Conflict domain. Participants described racial profiling from authorities, discrimination based on both skin and language differences, and being forced to live in substandard living conditions. Related to this are new experiences of economic stress, with many participants describing workplace discrimination and underemployment as new stress experiences. Also not described in the original HSI was both substance use and violence within the home. Participants described high rates of stress leading to domestic violence, infidelity, partner separation, and divorce. Finally, Hispanics appear to be experiencing heightened rates of stress within the family, with new descriptions of substance use and also stress from caring for elderly family members.

Cultural stressors also appear to cut across multiple domains for participants in this study. For example, the stress of discrimination was found in the experience of seeking a doctor, working with school teachers or principals, interacting with police, seeking and maintaining employment, and immigrating whether legally or otherwise. Substance use, a known behavioral health outcome due to stress, was found throughout discussions of both family, parenting, and marital stressor experiences. In addition, unemployment and underemployment are likely linked to living in higher density households, relating to increased family stress and the experience of having to take care of many family members, including the parents of spouses.

Stressful life events are connected to a multitude of negative health and behavioral health outcomes (Institute of Medicine [IOM], 2009; NIDA, 1995) and, as a group, many Hispanics are facing particularly stressful circumstances. Hispanics face disparate health outcomes including difficulty controlling high blood pressure, heightened rates of asthma, and increased risk for diabetes and cardiovascular disease (Morbidity and Mortality Weekly Report [MMWR, 2011). Hispanics also face heightened rates of HIV (Centers for Disease Control and Prevention [CDC], 2010), substance use and alcoholism (National Survey on Drug Use and Health [NSDUH], 2007), and mental health concerns (Prado et al., 2006). Furthermore, Hispanics have high rates of unemployment, which is related to a myriad of negative outcomes including poorer health outcomes and a lack of health insurance (U.S. Census, 2010).

The findings from this study may not reflect the stressor experiences of all Hispanics; however, two distinct study sites were chosen to garner a wide range of responses. Furthermore, more research is necessary to determine the validity of individual stressor items. An additional concern should be noted with regard to the sample. In total, 57% of participants reported being unemployed, which may mean their particular life experiences and subsequent stressor, are more applicable to this demographic segment of the Hispanic population.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Institute of Minority Health Disparities, Grant No. Grant1R43MD6150-01 to the first author.

Bios

Richard C. Cervantes received his PhD in psychology from Oklahoma State University. He is research director at Behavioral Assessment, Inc. and is senior research fellow at the California State University, Long Beach Center for Behavioral Research and Services Department of Psychology. He served as research psychologist at the UCLA Spanish Speaking Mental Health Research Center (1984-89) and held a full-time faculty appointment in the USC School of Medicine, Department of Psychiatry and the Behavioral Sciences (1990-1995). He has served as principal investigator on numerous NIH funded studies and has published extensively over a 25-year career span. His publications number more than two dozen scientific journal articles as well over a dozen book chapters relevant to Hispanic/Latino youth, family, mental health, and health issues. He is the developer of the Hispanic Stress Inventory and Familia Adelante, a family-focused behavioral health promotion program. Other research interests include investigation of issues related to Hispanic families, drug and alcohol abuse, cultural risk factors including migration/acculturation stress, and juvenile gangs.

Jeremy T. Goldbach received his PhD in social work from the University of Texas at Austin in 2012. He is a research associate with Behavioral Assessment, Inc. His scholarship focuses on the impact of minority stress on behavioral health outcomes in vulnerable youth, including Latinos and Lesbian, Gay and Bisexual (LGB) adolescents. His past research has explored the relevance of culturally grounded and family-based interventions to prevent high risk behaviors such as substance use and HIV.

Amado M. Padilla received his PhD in experimental psychology from the University of New Mexico. He is professor and chair of the program in developmental and psychological sciences, School of Education, Stanford University. A fellow of the American Psychological Association and the American Education Research Association, he has published 200 articles and chapters and 8 books on numerous topics ranging from psychological assessment, ethnic identity, acculturation, second language learning and teaching, foreign language education, and the education of immigrant students. He has served as a consultant to numerous regional and national organizations as well as governmental agencies that work with children and families in schools and mental health clinics.

References

Alva

de los Reyes

(1999). Psychosocial stress, internalized symptoms, and the academic achievement of Hispanic adolescents. Journal of Adolescent Research, 14, 343-358.

Antony

M. M.

Rowa

(2005). Evidence-based assessment of anxiety disorders in adults. Psychological Assessment, 17, 256-266.

Beck

Ward

Mendelson

Mock

Erbaugh

(1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.

Briere

(2004). Trauma Symptom Inventory (TSI). Odessa, FL: Psychological Assessment Resources.

Butcher

Cabiya

Lucio

Garrido

(2007). Assessing Hispanic Clients Using the MMPI-2 and MMPI-A. Washington, DC: American Psychological Association.

Centers for Disease Control [CDC] (2010). HIV among Hispanics/Latinos.

Retrieved March 24

from http://www.cdc.gov/hiv/hispanics/resources/factsheets/pdf/hispanic.pdf.

Cervantes

R. C.

Padilla

Salgado de Snyder

(1990). Reliability and validity of the HSI. Hispanic Journal of Behavioral Sciences, 12, 76-82.

Cervantes

R. C.

Padilla

Salgado de Snyder

(1991). The Hispanic Stress Inventory: A culturally relevant approach to psychosocial assessment. Journal of Consulting and Clinical Psychology, 3, 438-447.

Cervantes

R. C.

Córdova

Fisher

D. G.

Kilp

(2008, October). Development of the Hispanic Stress Inventory-Adolescent version: Preliminary findings. Poster presented at the annual conference of the National Hispanic Science Network on Drug Abuse, Washington, DC.

10.

Cervantes

R. C.

Dueñas

Valdez

Kaplan

(2006). Measuring violence risk and outcomes among Mexican American adolescent females. Journal of Interpersonal Violence, 21, 24-41.

11.

Cervantes

Fisher

D. G.

Córdova

Napper

L. E.

(2011). The Hispanic Stress Inventory-Adolescent Version: A culturally informed psychosocial assessment. Psychological Assessment. Advance online publication. doi:10.1037/a002528010.1037/a0025280

12.

Cohen

(1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement., 20, 37-46.

13.

Cordova

Cervantes

R.C.

(2010). Intergroup and within-group perceived discrimination among U.S. born and Foreign born Latino youth. Hispanic Journal of Behavioral Sciences, 32, 259-274.

14.

Cortés

D. E.

Gerena

Canino

Aguilar-Gaxiola

Febo

Magaña

. . . Eisen

S. V.

(2007). Translation and cultural adaptation of a mental health outcome measure: The BASIS-24. Culture, Medicine and Psychiatry, 31, 25-49.

15.

Costa

P. T.

Jr. McCrae

R. R.

(2006). Age changes in personality and their origins: Comment on Roberts, Walton, and Viechtbauer (2006). Psychological Bulletin, 132, 28-30.

16.

Cuellar

Arnold

Maldonado

(1995). Acculturation rating scale for Mexican Americans-II: A revision of the original ARSMA scale. Hispanic Journal of Behavioral Sciences, 17, 275-304.

17.

Cuellar

Harris

L. C.

Jasso

(1980). An acculturation scale for Mexican American normal and clinical populations. Hispanic Journal of Behavioral Sciences, 2, 199-217.

18.

Dwight-Johnson

Ell

Lee

(2005). Can collaborative care address the needs of low-income Latinas with comorbid depression and cancer? Results from a randomized pilot study. Psychosomatics, 46, 224-232.

19.

Fassinger

R. E.

(2005). Paradigms, praxis, problems, and promise: Grounded theory in counseling psychology research. Journal of Counseling Psychology, 52, 156-166.

20.

Finch

B. K.

Hummer

R. A.

Kolody

Vega

W. A.

(2001). The role of discrimination and acculturative stress in the physical health of Mexican-origin adults. Hispanic Journal of Behavioral Sciences, 23, 399-429

21.

Gerard

A. B.

(2005). Parent-Child Relationship Inventory (PCRI). Los Angeles, CA: Western Psychological Services.

22.

Guarnaccia

P. J.

Canino

Rubio-Stipec

Bravo

(1993), The prevalence of ataques de nervios in the Puerto Rico disaster study. The role of culture in psychiatric epidemiology. Journal of Nervous and Mental Disease, 181, 157-165.

23.

Guarnaccia

P. J.

Lewis-Fernandez

Rivera-Marano

(2003). Toward a Puerto Rican popular nosology: Nervios and ataque de nervios. Culture, Medicine and Psychiatry, 27, 339-366.

24.

Harris

R. J.

Firestone

J. M.

Vega

W. A.

(2005). The interaction of country of origin, acculturation, and gender role ideology on wife abuse. Social Science Quarterly, 86, 463-483.

25.

Hawkins

J. D.

Catalano

R. F.

Miller

J. Y.

(1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64-105

26.

Hunsley

Mash

E. J.

(2005). Introduction to the special section on developing guidelines for the evidence-based assessment (EBA) of adult disorders. Psychological Assessment, 17, 251-255.

27.

Institute of Medicine. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: National Academy of Sciences.

28.

Krippendorff

(2004a). Content analysis: An introduction to its methodology (2nd ed.). Thousand Oaks, CA: SAGE.

29.

Krippendorff

(2004b). Reliability in content analysis: Some common misconceptions and recommendations. Human Communication Research, 30, 411-433.

30.

Kubany

E. S.

(2004). Trauma Assessment Inventories. Los Angeles, CA: Western Psychological Services.

31.

LaRossa

(2005). Grounded theory methods and qualitative family research. Journal of Marriage and Family, 67, 837-857.

32.

Lofland

L. H.

(1995). Analyzing social settings. (3rd ed.). Belmont, CA: Wadsworth.

33.

Madrid

G. A.

MacMurray

Lee

Anderson

Comings

(2001). Stress as a mediating factor in the association between the DRD2 TaqI polymorphism and alcoholism. Alcohol, 23, 117-122.

34.

Malgady

R. G.

Zayas

L. H.

(2001). Cultural and linguistic considerations in psychodiagnosis with Hispanics: The need for an empirically informed process model. Social Work, 46, 39-49.

35.

Mangold

D. L.

Veraza

Kinkler

Kinney

N. A.

(2007). Neuroticism predicts acculturative stress in Mexican American college students. Hispanic Journal of Behavioral Sciences, 29, 366-383.

36.

Martinez

C. R.

(2006). Effects of differenctial family acculturation on Latino adolescent substance use. Family Relations, 55, 306-317.

37.

Morbidity and Mortality Weekly Report. (2011). Mental illness surveillance among adults in the United States. Atlanta, GA: Centers for Disease Control.

38.

McGuire

Martin

(2007). Fractured migrant families: Paradoxes of hope and devastation. Family and Community Health, 30, 178-188.

39.

National Survey on Drug Use and Health. (2007). Retrieved from http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/23782

40.

Nowack

K. M.

(1999). The stress profile. Los Angeles, CA: Western Psychological Services.

41.

Prado

Schwartz

Pattatucci-Aragón

Clatts

Pantin

Fernandez

M. I.

. . . Szapocznik

(2006). The prevention of HIV transmission in Hispanic adolescents. Drug and Alcohol Dependence, 84S, S43-S53.

42.

Rodriguez

Myers

H. F.

Mira

Flores

Garcia-Hernandez

(2002). Development of the Multidimensional Acculturative Stress Inventory for adults of Mexican origin. Psychological Assessment, 14, 451-461.

43.

Salgado de Snyder

Cervantes

R.C.

Padilla

(1990). Gender and ethnic differences in psychosocial stress and generalized distress among Hispanics. Sex Roles, 22(7), 441-453

44.

Santisteban

D. A.

Vega

R. R.

Suarez-Morales

(2006). Utilizing dissemination findings to help understand and bridge the research and practice gap in the treatment of substance abuse disorders in Hispanic populations. Drug and Alcohol Dependence, 84S, S94-S101.

45.

Snyder

D. K.

Heyman

R. E.

Haynes

S. N.

(2005). Evidence-based approaches to assessing couple distress. Psychological Assessment, 17, 288-307.

46.

Straus

(1987). Qualitative analysis for social scientists. New York, NY: Cambridge University Press.

47.

Strauss

Corbin

(1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed). Thousand Oaks, CA: SAGE.

48.

Straus

M. A.

(1979). Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family, 41, 75-88.

49.

Straus

M. A.

(1990). The Conflict Tactics Scale and its critics: An evaluation and new data on validity and reliability. In Straus

M.A.

Gelles

R. J.

, Physical violence in American families: Risk factors and adaptations to violence in 8,145 families (pp. 49-73). New Brunswick, NJ: Transaction.

50.

Suzuki

Ponterotto

J. G.

Meller

P. J.

(2007). Handbook of multicultural assessment: Clinical, psychological, and educational applications. San Francisco, CA: Jossey Bass.

51.

Thoman

L. V.

Suris

(2004). Acculturation and acculturative stress as predictors of psychological distress and quality-of-life functioning in Hispanic psychiatric patients. Hispanic Journal of Behavioral Sciences, 26, 293-311.

52.

U.S. Census (2010). Insurance. Retrieved from http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2010/highlights.html

53.

Vega

W. A.

Karno

Alegria

Alvidrez

Bernal

Escamilla

. . . Loue

(2007). Research issues for improving treatment of U.S. Hispanics with persistent mental disorders. Psychiatric Services, 58, 385-394.

54.

Vega

W. A.

Kology

Aguilar-Gaxiola

Alderate

Catalano

Carveo-Anduaga

(1998). Lifetime prevalence of SDM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55, 771-778.