Journal of Psychoactive Drugs, 47 (1), 51–59, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0279-1072 print / 2159-9777 online DOI: 10.1080/02791072.2014.994795

Substance Use among a National Sample of Asian/Pacific Islander Men Who Have Sex with Men in the U.S. Eric J. Nehl, Ph.D.a ; Jennifer H. Han, M.Sc.b ; Lavinia Lin, M.P.H.c ; Kyogo K. Nakayama, M.P.H.d ; Yu Wu, M.D., M.P.H.d ; Frank Y. Wong, Ph.D.e & The MATH Consortiumf

Abstract —The objectives of this study were to describe drug use among Asian/Pacific Islander (API) men who have sex with men (MSM) and to examine how nativity (and acculturation as a secondary correlate) predicted such use. A total of 445 self-identified API MSM from seven metropolitan cities participated in a national HIV serological testing and psychosocial and behavioral assessment study. Results indicate clubbing was significantly associated with higher levels of substance use. Additionally, participants who were U.S.-born were more likely to have reported marijuana use and those with higher levels of acculturation reported less marijuana use. Our bivariate findings suggest that foreign-born status and acculturation experience may provide a protective effect against marijuana use among API MSM. These associations largely did not hold in our multivariate models. Future research should more fully examine the role of acculturation and nativity in substance use behaviors. Keywords — Asian and Pacific Islanders, MSM, substance use

INTRODUCTION As of 2008, there were 16.6 million Asian/Pacific Islander (API) residents in the U.S., representing approximately 5.4% of the total population (U.S. Census Bureau News 2010). Asians and Native Hawaiians and Pacific Islanders, as a group, experienced 2.7% and 2.4% growth,

respectively, between 2007 and 2008, the two highest of any race group during that time (U.S. Census Bureau News 2010). However, the API population represents one of the most poorly understood minority groups in terms of their healthcare needs and behaviors (Islam et al. 2010). It is critical to recognize their importance and develop appropriate public health research and programs.

a Assistant Research Professor, Emory University’s Rollins School of Public Health, Atlanta, GA. b Research Assistant, Johns Hopkins University, School of Nursing, Baltimore, MD. c Senior Research Associate, Emory University’s Rollins School of Public Health, Atlanta, GA. d Research Assistant, Emory University’s Rollins School of Public Health, Atlanta, GA. e Associate Professor, Emory University’s Rollins School of Public Health, Atlanta, GA. f The MATH Consortium consists of the following organizations: AIDS Services in Asian Communities (Philadelphia, PA), Asian

Americans for Community Involvement (San Jose, CA), Asian Health Services (Oakland, CA), the Asian & Pacific Islander Coalition on HIV/AIDS (New York, NY), the Asian Pacific AIDS Intervention Team (Los Angeles, CA), the Asian and Pacific Islander American Health Forum (San Francisco, CA), the Asian & Pacific Islander Wellness Center (San Francisco, CA), Massachusetts Asians and Pacific Islanders for Health (Boston, MA), Georgetown University, George Washington University, and Emory University. Please address correspondence to Eric J. Nehl, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road, N.E., Atlanta, GA 30322; phone: 404-727-9445; fax: 404-727-1369; email: [email protected]

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Substance Use among APIs in the U.S. Studies on substance use among APIs are somewhat limited, with only 43 empirical studies of substance use among APIs published in peer-reviewed journals between 1970 and 2003 (Wong et al. 2007). These studies, however, have not produced consistent findings. For instance, there has been some indication that API men who have sex with men (MSM) have lower rates of substance use than MSM of other ethnicities (Thiede et al. 2003), disputing the argument of a syndemic phenomenon in this subpopulation of gay/bisexual men. If a syndemic were occurring in API MSM, then research would expect to find multiple intertwined health problems occurring in a population simultaneously experiencing poor physical and social conditions (Singer & Clair 2003). However, other studies have found that these men have comparable or slightly higher rates of substance use behaviors (Choi et al. 2005; Operario et al. 2006). Reasons for these differences in findings across studies are not clear, but may be associated with different sampling techniques, the type of participant being recruited, or temporal drug use trends. The most commonly reported substances among API MSM are alcohol, followed by marijuana and club drugs (Greenwood et al. 2001; Operario et al. 2006; Thiede et al. 2003). One study found that young API MSM were more likely to initiate marijuana and other drug use compared to heterosexual API young men (Hahm et al. 2008). Furthermore, a venue-based study in San Francisco reported substance use among API MSM to be: alcohol use (94% lifetime, 89% past six months), marijuana (61% lifetime, 44% past six months), and ecstasy (58% lifetime, 47% past six months). In addition, 24% used an illicit substance weekly or more often, 51% used club drugs, and 44% used three or more illicit substances in the past six months (Operario et al. 2006). Study findings also showed that nearly half of the 566 API MSM reported engaging in unprotected anal intercourse while under the influence of an illicit substance (Operario et al. 2006). In a study of 496 API MSM, Choi et al. reported that about one-third of API MSM participants used alcohol (32%) or drugs (34%) during sex (Choi et al. 2005). Substance use has consistently been associated with sexual risk for HIV in various ethnic MSM communities (Ostrow 2000; Ross & Williams 2001), and this behavioral pattern is emerging in the APIs (Choi et al. 2005; Nemoto et al. 2003; Operario et al. 2006).

immigrant health advantage concept. Evidence has shown that the being from the first or second generation, compared to the third generation, of Asian Americans was associated with decreased substance use (Loue & Sajatovic 2012). This diminished with increased acculturation and time in U.S. residency (Blake et al. 2001; Chen et al. 1999; Epstein, Botvin & Diaz 2001; Gfroerer & Tan 2003; Ojeda et al. 2008; Vega, Gil & Zimmerman 1993; Wagnerecheagaray et al. 1994). The differences in cultural values and behaviors, historical customs, and environment may influence engagement in delinquency behaviors. Age at immigration to the U.S. has also been indicative of risk for substance use; those who moved to the U.S. at an older age were less likely to consume alcohol or other drugs (Wong et al. 2007). Nativity status has also been linked with elevated risk for drug use problems among API groups (Dias et al. 1981; Morgan, Wingard & Felice 1984). Meanwhile, it is difficult to disentangle the acculturation process, a byproduct or correlate of nativity, in that it is a significant source of stress that has been associated with overall health and substance use risk (Al-Issa & Tousignant 1997). In one study, acculturation was found to explain 40% of the observed nativity difference in risk for drug dependence (Turner et al. 2006). The present study explored the role of nativity (and acculturation as a secondary correlate) in substance use behaviors among a national sample of API MSM. To our knowledge, no study has exclusively focused on the examination of the interaction between nativity and substance use in this population. The aims of the study were to (1) describe the use of various drugs among API MSM; and (2) examine how nativity and acculturation predicted such use. METHODS Study Design and Participants Data collected between June 2007 and August 2009 from a national study with community-based participatory research design (N = 445) known as “Men of Asia Testing for HIV” (MATH) were used in the present analysis. Eligible participants (i.e., self-identified as API ethnicity; MSM; aged 18+; had sex with another man in the last 12 months; had resided in the targeted city in the last six months; able to provide verbal and written informed consents in English, Chinese, or Vietnamese [two most common Asian languages in the U.S.]; and willingness to participate in HIV screening and confirmatory testing) were recruited through a purposive and convenience sampling from seven community-based organizations in seven metropolitan cities (Boston, Los Angeles, New York City, Oakland, Philadelphia, San Francisco, and San Jose) that provide HIV-prevention programming, screening, and testing. Recruitment advertisements included (1) standard outreach, such as distributing flyers and postcards in gay

Nativity and Substance Use Nativity (defined in this study as country of birth) plays a central role in shaping health outcomes, including substance use (Eitle, Wahl & Aranda 2009; Ojeda, Patterson & Strathdee 2008; Turner, Lloyd & Taylor 2006; Wahl & Eitle 2010), general health status (Cho, Frisbie & Rogers 2004; Uretsky & Mathiesen 2007), and mental health (Takeuchi et al. 2007). Prior research about the role of nativity on substance use has indicated some concordance with the Journal of Psychoactive Drugs

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bars, venues, and public sex areas; (2) announcements via mainstream (e.g., gay pride) and ethnic-specific gay events; and (3) announcements via Internet. The study protocol was approved by the Institutional Review Board of Georgetown University. After completing informed consent procedures, participants received a self-administered paper-and-pencil questionnaire which took about 30–45 minutes to complete. English, Mandarin, and Vietnamese versions of the survey were available. To ensure participant confidentiality, identifying information was removed from the datasets and surveys were stored in a locked file cabinet. All protocols, surveys, and study materials for participants underwent standard, rigorous translation and back-translation for each language.

gay community,” and “Gay men of color are an important part of this city’s community.” Composite summary scores were created for gay acculturation. Internal consistency was .73 (.70 for U.S.-born and .74 for non-U.S. born). Substance use. Participants were asked about their use of various substances (yes/no response) for two different time periods: (1) lifetime usage; and (2) usage in the past 12 months. Participants were also asked about their substance use before or during sex specifically. Substances were organized into four major categories: alcohol, marijuana, club drugs, and hard drugs. Club drug use was defined as any use of methamphetamine, poppers/nitrate inhalants, MDMA/ecstasy, GHB, and ketamine/Special K (National Institute on Drug Abuse 2012a). Use of hard drugs was defined as reports of any use of cocaine, crack, LSD, downers, opium, or heroin (Nutt et al. 2007). To provide comparisons to previous research, polydrug use reflected the reporting of using three or more illicit drugs, excluding marijuana (Operario et al. 2006). Participants were asked how often they went clubbing and to a sex venue in the past 12 months. In this study, sex venues were defined as private sex parties, sex clubs, bathhouses, and public cruising areas, such as a park, beach, bookstore, or restroom. They were also asked if they ever attended a circuit party in the past 12 months.

Measures Socio-demographic characteristics. In addition to socio-demographic variables, such as age, place of birth, and sexual orientation, we were interested in the intersection of nativity, acculturation, and substance use behaviors. For nativity, participants were asked where they were born (i.e., in the U.S. or outside the U.S.). Participants who were not born in the U.S. were asked about their age at arrival to the U.S. and number of years in the U.S. For acculturation, an abbreviated 42-item multidimensional acculturation scale, also known as AMAS-ZABB, was utilized (Zea et al. 2003). The AMAS-ZABB is a scale with 4-point Likert-type response options, ranging from 1 (strongly disagree) to 4 (strongly agree) for the cultural identity sub-scales, and from 1 (not at all) to 4 (extremely well/like a native) for the language and cultural competence sub-scales. Sample items of the U.S. acculturation included “I think of myself as being U.S. American,” and “I feel that I am part of U.S. American culture.” Similar statements were asked to measure ethnic acculturation, such as “Being a member of API plays an important part in my life,” and “I am proud of being an API.” Index scores, one representing the U.S. American dimension and the other representing culture of origin, were calculated by averaging the three sub-scales of identity, language competence, and cultural competence for each dimension (Zea et al. 2004). Internal consistency for the American acculturation component of the scale from this sample was .87 (.83 for U.S.born and .86 for non-U.S.-born). Internal consistency for ethnic acculturation component of the scale from this sample was .85 (.83 for U.S.-born and .84 for non-U.S.-born). A scale developed by the last author was used to assess acculturation to gay culture and lifestyle. Using 4-point Likert-type response options, ranging from 1 (strongly disagree) to 4 (strongly agree), questions inquired about participants’ perceptions of the gay community and their own involvement or role in the gay community. Sample items included “You feel like you’re a part of this city’s Journal of Psychoactive Drugs

Data Analysis First, descriptive statistics, overall and stratified by nativity (i.e., non-U.S.-born vs. U.S.-born), were used to characterize socio-demographics and substance use patterns. Lifetime and past 12 months use was reported by substance use category: alcohol, marijuana, club drugs, and hard drugs. Second, one-way ANOVAs with nativity (U.S.-born or non-U.S.-born) as the between-subjects factor for continuous variables and chi-squares for categorical variables were used to compare participant groups. Third, Spearman and Pearson correlations were used to explore bivariate relationships between substance use, demographics, and psychosocial scales, and to determine their suitability for entry into multivariate analyses, using a selection criterion of p < .05. Those variables related to our study aims (e.g., the relationships of nativity and acculturation to substance use) and with consistently significant relationships (e.g., age, nativity, frequency of clubbing) with the outcome variables (p < .05) were retained and used consistently across the final models. Other variables, such as coast of recruitment, which did not exhibit significant bivariate relationships, were not retained for the final regression models. Last, logistic regression analyses were conducted to determine factors associated with levels of substance use in the past 12 months with forced entry of predictors (variables were entered all at once) into the model. Interaction terms were created and entered into the model 53

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to examine the possible moderating influence of nativity on the relationship between American/ethnic acculturation and substance use behaviors.

higher on the ethnic acculturation scale were less likely to report marijuana use in the past 12 months (OR = 0.52, CI 0.29, 0.92). Multivariate analyses showed that while older participants were less likely to report alcohol use (OR = 0.96, CI 0.94, 0.98), they were more likely to report polydrug (OR = 1.05, CI 1.02, 1.08) and hard drug use (OR = 1.04, CI 1.01, 1.08). None of the nativity and acculturation interaction terms were statistically significant.

RESULTS Socio-Demographic Characteristics Socio-demographic characteristics of the sample (N = 455) are summarized in Table 1. A roughly equal number of non-U.S.-born (52.4%) and U.S.-born (46.5%) participants enrolled in the study. More than one-third of them (36.2%) identified as Southeast Asian, followed by Asian American (27.4%) and East Asian (26.5%). The mean age of participants was 30.7 years (SD = 10.3); U.S.-born participants were significantly (p = 0.01) younger than non-U.S.-born participants. A majority of the participants were located in the West Coast (87.4%); non-U.S.-born participants were significantly (p < .01) more likely to be recruited from the East (15.9%) than West (8.2%) Coast. Most of the participants (83.3%) identified themselves as gay, with a mean age of first having intimate physical contact with another man in person of 17.6 years (standard deviation = 5.4). Going to sex venues other than clubbing differed by nativity, with those non-U.S.-born reporting more likely to be venue users in the past year and month (p = 0.01). U.S.-born participants scored predictably higher on the American acculturation scale (p < 0.001) and similarly, non-U.S-born participants were more likely to score higher on the ethnic acculturation score (p < 0.001).

DISCUSSION Results indicate that overall there is a significant level of drug use in our study population—the majority reported alcohol use and approximately one-third of the sample reported marijuana use, representing the most commonly used substances. The next most commonly used substances were club drugs, specifically ecstasy and poppers. This is consistent with other studies involving MSM participants, although the use of methamphetamines and LSD was higher in other studies (Greenwood et al. 2001; Operario et al. 2006; Thiede et al. 2003). The lower methamphetamine use and difference by coast in this study was surprising considering that the majority of participants were from the West Coast, where methamphetamine use is more common (Hunt, Kuck & Truitt 2006). When compared to other API MSM studies, these substance use estimates appear lower (Operario et al. 2006; Thiede et al. 2003). When juxtaposed with the API MSM sample in San Francisco (Operario et al. 2006), for example, lifetime club drug and poly-drug use was 51% and 44%, respectively (Operario et al. 2006), whereas our estimates were 39.4 and 24.2%. This is similar to the poly-drug use of only the API participants in a multi-site study (Thiede et al. 2003), which was 18.6%. However, direct comparisons with these studies must be interpreted with caution. In the prior studies, participants were significantly younger (15 to 22 years of age (Operario et al. 2006) and 18 to 29 years of age (Thiede et al. 2003) and were recruited exclusively from San Francisco (Operario et al. 2006). In comparison, our study participants were older (mean age of 30.7 years) and were recruited from a multi-site sample that included major metropolitan areas in the U.S. These differences may explain the differences in substance use among our participants. In the U.S. general population, people usually begin using drugs during their teenage years and very few begin before age 10 or after 25 (Substance Abuse and Mental Health Services Administration 2013). However, our multivariate analyses revealed that older participants reported less alcohol use but higher poly-drug and hard drug use (Table 3). To explain the contradictory finding, our study participants may have initiated drug experimentation at an older age and, therefore, this is the residual effect of delayed initiation. Considering that about half of our sample consisted of non-U.S.-born participants, age of

Substance Use Behaviors Patterns of substance use by nativity and by individual drug are reported in Table 2. Overall, alcohol (79.8%), marijuana (33.7%), poppers (15.9%), and ecstasy (15%) were the most commonly reported substances in the past 12 months. Specifically, U.S.-born participants reported higher use of alcohol (p = 0.04 for past 12 months) and marijuana (p < 0.01 for past 12 months) than non-U.S-born participants. Marijuana use before sex was also reported significantly more often (p < .05) among U.S.-born participants (21%) than non-U.S.-born participants (12.4%). Multivariate Analysis of Substance Use As can be seen in Table 3, compared to those who reported not going to clubs and bars at all, participants who reported going at least once a month were more likely to report alcohol (OR = 3.75 CI 1.64, 8.56), marijuana (OR = 3.87, CI 1.45, 10.32), poly-drug (OR, = 14.16, CI 1.72, 116.39), club drug (OR = 6.16, CI 1.99, 19.08), and hard drug use (OR = 6.06, CI 1.28, 28.77). Nativity and ethnic acculturation (more Asian identified) were found to be associated only with marijuana use: (1) U.S.-born participants were more likely to report marijuana use in the past 12 months compared to non-U.S.-born participants (OR = 2.31, CI 1.36, 3.92); and (2) participants who scored Journal of Psychoactive Drugs

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TABLE 1 Socio-Demographics of MATH Study Participants

Variable Age Age when came to United States Years in US Age when first realized that you are attracted to men Age when first had intimate physical contact or physical sex with another man in person What is your sexual orientation? Gay Other Location: East or West Coast East West City Boston Los Angeles New York City Oakland Philadelphia San Francisco San Jose How do you describe your ethnicity or cultural background? Asian American Southeast Asian East Asian South Asian Mixed Hawaiian and Pacific Islander Have you ever had any form of sexual or intimate contact with a woman in your life? No Yes Frequency of clubbing1 in past 12 months Not at all At least once a year At least once a month Frequency of sex venue use2 in past 12 months Not at all At least once a year At least once a month Ever attended a circuit party in the past 12 months No Yes American acculturation Ethnic acculturation Gay acculturation

Overall (N = 445) M or % (SD) 30.7 (10.3) 15.2 (9.9) 17.0 (9.9) 11.6 (4.5)

US-Born (n = 207) M or % (SD) 29.5 (11.1)

11.3 (4.3)

Non-US-Born (n = 233) M or % (SD) 31.9 (9.4) 15.1 (9.8) 17.0 (9.9) 11.9 (4.6)

17.6 (5.4)

17.3 (4.9)

17.9 (5.7)

F = 3.45

83.3 16.7

80.6 19.4

85.7 14.3

x2 (1) = 2.06

12.6 87.4

8.2 91.8

15.9 84.1

x2 (1) = 5.99∗∗

1.4 28.2 8.0 19.8 3.2 27.7 11.8

1.4 34.3 4.3 21.3 2.9 30.4 5.3

1.3 22.7 11.2 18.5 3.4 25.3 17.6

27.4 36.2 26.5 0.7 6.2 3.0

32.7 28.3 27.8 0 7.8 3.4

22.7 43.2 25.3 1.3 4.8 2.6

x2 (5) = 15.33∗∗

59.1 40.9

57.3 42.7

60.8 39.2

x2 (1) = 0.55

10.4 35.8 53.9

10.9 38.3 50.7

9.8 33.5 56.7

x2 (2) = 1.52

52.1 32.3 15.6

59.6 26.3 14.1

45.6 37.6 16.8

x2 (2) = 8.67∗∗

70.7 29.3 0.54 0.59 0.90

74.1 25.9 0.44 0.58 0.58

67.6 32.4 0.54 0.54 1.11

x2 (1) = 2.14

Test Statistic F = 3.54∗∗ F = 0.51

x2 (6) = 27.17∗∗

F = 70.29∗∗∗ F = 48.60∗∗∗ F = 2.49

Note: N varies based on missing responses. ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001. 1 Clubbing includes a summation of responses to two items in the survey: visiting “bar” or “night club or dance club.” 2 Sex venue use includes a summation of responses to three items in the survey: visiting “private sex parties,” “sex clubs,” “bathhouses,” or “public cruising areas, such as a park, beach, bookstore or restroom.”

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TABLE 2 Descriptive Statistics and Chi-Square Comparison of Nativity (US-Born vs. Non-US-Born)

Have you used the following drugs in the past 12 months? Alcohol Marijuana (pot, hash, 420) Club Drugs Methamphetamine Poppers Ecstasy GHB Special K Hard Drugs Cocaine Crack LSD Downers Opium Heroin Have you ever used the following drugs in your whole life? Alcohol Marijuana (pot, hash, 420) Club Drugs Hard Drugs In the past year, which of the following drugs did you use during or just before having sex? Alcohol Marijuana (pot, hash, 420) Club Drugs Hard Drugs

Overall (N = 445) %

US Born (n = 207) %

Non-US Born (n = 233) %

79.8 33.7 27.8 7.8 15.9 15.0 5.0 2.4 12.1 8.6 3.6 2.1 2.4 1.9 1.9

84.0 47.0 31.5 8.0 16.5 19.0 6.0 3.0 12.0 8.0 4.0 1.0 2.5 1.5 1.0

75.9 21.7 24.4 7.7 15.4 11.3 4.1 1.8 12.2 9.0 3.2 3.2 2.3 2.3 2.7

x2 x2 x2 x2 x2 x2 x2 x2 x2 x2 x2 x2 x2 x2 x2

(1) = 4.20∗ (1) = 30.02∗∗ (1) = 2.61 (1) = 0.01 (1) = 0.10 (1) = 4.88∗ (1) = 0.82 (1) = 0.64 (1) = 0.01 (1) = 0.15 (1) = 0.21 (1) = 2.36 (1) = 0.026 (1) = 0.33 (1) = 1.66

83.2 42.8 39.4 21.6

87.5 57.5 45.0 25.0

79.2 29.4 34.4 18.6

x2 x2 x2 x2

(1) = 5.15∗ (1) = 33.84∗∗ (1) = 4.95∗ (1) = 2.58

50.6 16.5 20.5 8.2

53.8 21.0 21.5 7.0

47.7 12.4 19.6 9.3

x2 x2 x2 x2

(1) = 1.52 (1) = 5.63∗ (1) = 0.25 (1) = 0.76

Test Statistic

Note: ∗ p < .05; ∗∗ p < .01. Club drugs include methamphetamine, poppers/nitrate inhalants, MDMA/ecstasy, GHB, and ketamine/Special K. Hard drugs include cocaine, crack, LSD, downers, opium, and heroin.

immigration to the U.S. may delay the age of first drug use (Nemoto et al. 1999; Wong et al. 2007). Unfortunately, the age at which participants first started using drugs was not collected in our study. Nativity was associated with marijuana use only, revealing that U.S.-born participants had greater odds of reporting marijuana use in the past 12 months than nonU.S.-born participants. Marijuana is often seen as a harmless, inexpensive, and readily available drug. It is also reported as the most commonly used illegal drug in the United States (National Institute on Drug Abuse 2012b). U.S.-born participants may have greater access to substances when they are more fluent in English or more in touch with local customs for obtaining drugs (Gfroerer & Tan 2003). This is one possible reason for the association; however, further research is needed. Regardless of the type of substance use, the most consistent finding from Journal of Psychoactive Drugs

the multivariate logistic models is that clubbing (which includes going to bars) was associated with greater use of all five substance-use outcomes. Compared to those who reported “not going at all,” individuals who go clubbing at least once a month were more likely to report poly-drug use. As many as 10.4% of the API MSM in our study have stated that they do not go clubbing at all; this has implications with the comparison of our substance use findings with other studies involving MSM (Operario et al. 2006; Thiede et al. 2003), because the majority of their study participants were recruited from bars and similar venues. Ethnic acculturation was associated only with marijuana use. Those scoring higher on the ethnic acculturation scale (more Asian identified) were less likely to report marijuana use in the past 12 months. This finding, in conjunction with the finding that nativity may also have a complex relationship with marijuana use, invokes further 56

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TABLE 3 Multivariate Logistic Models of Substance Use: 12-Month Outcome Variables

Age Nativity US-Born Non-US-Born Frequency of Clubbing Not at all At least once a year At least once a month American Acculturation Ethnic Acculturation Nativity × American Acculturation Nativity × Ethnic Acculturation

Adjusted OR (95% CI) Poly-Drug Use Club Drug Use 1.05 (1.02−1.08)∗∗ 1.02 (1.00−1.05)

Alcohol Use Marijuana Use 0.96 (0.94−0.98)∗∗ 0.98 (0.95−1.00) 1.18 (0.63−2.20) 1.00

2.31 (1.36−3.92)∗∗ 1.00

1.53 (0.71−3.31) 1.00

1.14 (0.64−2.01) 1.00

Hard Drug Use 1.04 (1.01−1.08)∗∗ 1.06 (0.52−2.16) 1.00

1.00 1.00 1.00 1.00 1.00 1.87 (0.85−4.12) 2.05 (0.76−5.51) 5.26 (0.64−43.12) 2.70 (0.87−8.42) 2.50 (0.52−12.02) 3.75 (1.64−8.56)∗∗ 3.87 (1.45−10.32)∗∗ 14.16 (1.72−116.39)∗ 6.16 (1.99−19.08)∗∗ 6.06 (1.28−28.77)∗ 1.84 (0.69−4.94) 1.71 (0.78−3.74) 2.08 (0.64−6.75) 2.07 (0.84−5.08) 0.65 (0.21−2.05) 0.76 (0.35−1.63) 1.05 (0.56−1.99)

0.52 (0.29−0.92)∗ 1.15 (0.65−2.02)

0.79 (0.39−1.63) 0.92 (0.41−2.07)

0.67 (0.37−1.20) 0.65 (0.36−1.17)

0.93 (0.42−2.07) 1.77 (0.82−3.82)

1.06 (0.58−1.93)

1.14 (0.69−1.88)

0.69 (0.36−1.33)

0.93 (0.57−1.53)

0.59 (0.31−1.14)

Note: ∗ p < .05; ∗∗ p < .01.

research. In particular, it would be important to understand why this trend was not found with other substances and whether this effect persists after prolonged years residing in the U.S. There are several limitations in this study. First, this study recruited participants through several modalities and a cross-sectional design; therefore, no causal inferences can be made. Second, self-reported data is inferior to an objective assessment. Therefore, future studies should increase the validity of drug use assessment among API MSM by using objective measurements. Third, generalization to all API MSM is limited because the sample was recruited through a non-probability sampling methodology from seven metropolitan areas. Substance use behaviors and trends are influenced by geography and cultural phenomena specific to an area (Thiede et al. 2003); recruitment was limited to only East Coast and West Coast cities, and the majority of the participants were recruited from the West Coast. Another potential concern is that individuals who chose to participate in the MATH study may be different from those who did not. Information on important potential socio-demographic confounders, such as education and income level, was not collected, and information on how an individual pays for his healthcare was used as our closest proximate socioeconomic status. Despite these limitations, there are several implications for the field. Including a multi-city sample as well as providing surveys in Asian languages are critical to understanding the full spectrum of cultural, linguistic, socio-demographic, and historical contexts that APIs encompass. This study examined substance use behaviors Journal of Psychoactive Drugs

in a diverse sample of API MSM in regards to geography, race and ethnicity, and nativity. In addition, it narrowed the gap in the need to engage in communitycollaborative endeavors and conduct quantitative epidemiological research of API MSM in various geographic locations (Operario et al. 2006). The examination of the specific role of nativity and acculturation in substance use behaviors is a different and unique framework. Future research, particularly qualitative data, is needed to understand the underlying dynamics of the API MSM community. It would be useful to explore the role of culture and nativity in determining choices an API MSM individual makes in regards to choice of drug as well as risk-taking behaviors. From this study, we discovered that our non-U.S.-born participants may possess an immigrant health advantage against marijuana use, at least initially. Study results indicate that API MSM are not immune to harmful substance use behaviors and support the need for culturally and linguistically sensitive outreach, education, and treatment services for API MSM. Because of the close relationship between substance use and HIV/AIDS, future research should also examine the role of nativity and acculturation and its impact on substance use and risky sexual behaviors. In conclusion, this study supports the notion that acculturation adds another layer to our understanding of nativity—that nativity is not a single, simple concept of where someone is born. In order to understand the role nativity plays in substance use behaviors, it is important to account for the varying levels of acculturation experiences resulting from one or both groups. Moving forward, there needs to be: (1) development of innovative programs 57

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that are cognizant of the unique needs of API MSM; and (2) the incorporation of nativity, acculturation, and linguistic considerations in future research.

FUNDING Preparation of this article was supported in part by grants from the National Institutes of Health (R01HD046354; PI: Wong) and the Emory Center for AIDS Research (P30 AI050409; Nehl and Wong). The funders had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

ACKNOWLEDGMENTS Jennifer H. Han and F.Y. Wong conceptualized the study; E.J. Nehl supervised the analytic process; Y. Wu performed the analyses. Han contributed to the initial writing; all contributed to the interpretations of the findings.

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Pacific Islander Men Who Have Sex with Men in the U.S.

The objectives of this study were to describe drug use among Asian/Pacific Islander (API) men who have sex with men (MSM) and to examine how nativity ...
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