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CHAPTER 14 Theory of Cultural Marginality

Heeseung Choi

As transportation and communication technology advance, there is a comple- mentary increase in contacts between culturally distinct populations. The num- ber of immigrants has continued to grow; as of 2015, about 13.5% (43.3 million) of the U.S. population was foreign-born (Migration Policy Institute, 2017). Approximately 16% of these immigrants reported entry since 2010 (Migration Policy Institute, 2017). Although society is becoming more and more ethnically and culturally diverse, the lack of mutual understanding between healthcare providers and clients from different cultural backgrounds remains a barrier to progress in healthcare services for immigrants. The Theory of Cultural Marginality was developed to increase understanding of the unique experi- ences of individuals who are straddling distinct cultures and to offer direction for providing culturally relevant care.

■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

While working with immigrant adolescents and living in the United States as an immigrant, I noticed unique circumstances that immigrant adoles- cents encountered as a result of the immigration process and the impact of the process on their mental health. A review of related theories and research on immigrant adolescents’ mental health issues provided the foundation for developing a program of research that began with Korean American adoles- cents. In a community-based study, I discovered that Korean American ado- lescents demonstrated signifi cantly lower levels of self-esteem, coping skills, and mastery in addition to higher levels of depression and somatic symp- toms than American adolescents (Choi, Stafford, Meininger, Roberts, & Smith, 2002). The response pattern was more prominent among foreign-born Koreans than U.S.-born Koreans. In a subsequent school-based study, compared with Whites, Asian and Hispanic American adolescents experienced higher levels of social stress and somatic symptoms and depression (Choi, Meininger, & Roberts, 2006). Among White, African, Hispanic, and Asian Americans, Asian American adolescents reported the lowest scores on self-esteem, coping, and family cohesiveness, and the highest score in family confl icts (Choi et al., 2006).

Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0014

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These fi ndings led to an exploration of the reasons for the adolescents’ vul- nerability and to examining the stress of the immigration process as a signifi - cant risk factor for mental distress. The next step in building my program of research required an extensive literature review searching for theories that con- tributed to understanding how distress was associated with immigration for Asian American adolescents.

Theories contributing to the development of the Theory of Cultural Marginality were acculturation, acculturative stress, and marginality. Acculturation was fi rst defi ned by the Social Science Research Council (SSRC) as “phenomena which result when groups of individuals having different cultures come into continuous fi rst-hand contact, with subsequent changes in the original cultural patterns of either or both groups” (Redfi eld, Linton, & Herskovits, 1936, p. 149). Theories addressing acculturation have undergone many changes over time, expressed originally through unidimensional mod- els to current expression as multidimensional and orthogonal models (Berry, Poortinga, Segall, & Dasen, 1992; Keefe & Padilla, 1987; Oetting & Beauvais, 1990–1991; Vega, Gil, & Wagner, 1998). The Unidimensional Bipolar Model suggested that individuals inevitably lost their culture of origin as they became acculturated into a new culture (Redfi eld et al., 1936). Individuals were believed to have only two options: either they acculturated or they remained in their old culture. On the other hand, the Multidimensional Model focuses on the complex nature of acculturation and selective, or uneven, acculturation across domains of social life (Berry et al., 1992; Keefe & Padilla, 1987; Vega et al., 1998). The Orthogonal Model proposes bicultural- ity and assumes that acculturating individuals could maintain two different cultural identities simultaneously (Oetting & Beauvais, 1990–1991). An indi- vidual may identify himself or herself as a member of both cultural groups, not necessarily choosing either cultural group. These two models opened a new era for theories of acculturation.

One of the popular approaches to acculturation is the Fourfold Theory of Acculturation (Berry, 1995; Berry & Kim, 1988; Berry et al., 1992). The Fourfold Theory explains strategies that acculturating individuals use. Depending on the chosen culture of reference, strategies are categorized as assimilation, sepa- ration, integration, and marginalization.

In assimilation, individuals give up their cultural identity and are absorbed into the dominant, or new, culture. Separation, by contrast, is withdrawal from the dominant culture to reside within the old culture. Integration is regarded as the ideal response and involves “making the best of both worlds” (Berry et al., 1992, p. 279). In marginalization, individuals lose their cultural and psycho- logical contacts with both cultures. Theories of acculturation are broad-rang- ing and complex, incorporating social, economic, and political components, as well as values, attitudes, self-identity, and behavior change components (Berry & Kim, 1988; Berry et al., 1992).

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Acculturative stress—a second theory that contributed to cultural marginal- ity—was developed to highlight the link between acculturation and mental health outcomes. Acculturative stress was defi ned by Vega et al. (1998) as “a by-product of acculturation that is specifi c to personal exposure to social situa- tions and environments that challenge individuals to make adjustments in their social behavior or the way they think about themselves” (p. 125). Individuals experience acculturative stress during the acculturating process or as a result of discrimination or being different (Chavez, Moran, Reid, & Lopez, 1997). Acculturative stress has been associated with declining mental health status in acculturating immigrants (Gil, Wagner, & Vega, 2000; Hovey & Magana, 2002; Noh & Kaspar, 2003). The intensity of the relationship between acculturative stress and mental health outcomes is determined by a number of moderating factors including the nature of the dominant culture and the characteristics of the acculturating individuals and groups (Berry & Kim, 1988; Berry et al., 1992).

The third theory to contribute to the development of the Theory of Cultural Marginality was the Theory of Marginality. The Theory of Marginality was fi rst proposed by Park in 1928. Park introduced the “marginal man” concept with special attention to social context (Park, 1928, p. 893). He described the marginal man as experiencing confl icts of the divided self, the old and new self, a lack of integrity, spiritual instability, restlessness, malaise, and moral turmoil between at least two cultural lives. Stonequist (1935) further explored the nature, variations, social situations, and life cycle of the marginal man. By Stonequist’s (1935) defi nition, life cycles consist of an introductory period of preparation, a crisis period, and an adjustment period that may provide opportunities and impetus for social and psychological growth. The Theory of Marginality has been applied to a wide range of situations, such as middle managers’ experiences in the social hierarchy of the workplace (Ziller, 1973), student nurses’ experiences (Andersson, 1995), and menopause experiences (Im & Lipson, 1997).

In nursing, Hall, Stevens, and Meleis (1994) defi ned marginality as the con- dition of being peripheralized from mainstream society or the center of the society based on identity, status, and experience. Marginalization and margin- ality were viewed from a sociopolitical perspective in relation to racial, gender, political, or economic oppression and were scrutinized along with inequities in economic, political, and social power and resources (Hall, 1999; Hall et al., 1994).

The broad perspective that characterizes the theories of acculturation, accul- turative stress, and marginality has led to criticisms that cite vagueness and a lack of empirical support (Del Pilar & Udasco, 2004; Rudmin, 2003) as major weaknesses. Del Pilar and Udasco (2004) claimed that marginality contains so many different layers of experiences that it is impossible to explain it in a unifi ed way. Keeping in mind the strengths as well as the limitations and

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criticisms of the previous theories, I began by defi ning cultural marginality. The fi rst defi nition of cultural marginality was “situations and feelings of pas- sive betweenness when people exist between two different cultures and do not yet perceive themselves as centrally belonging to either one” (Choi, 2001, p. 198). With continued contemplation of this defi nition, thoughtful ongoing review of the literature, and research with immigrant adolescents, the Theory of Cultural Marginality developed. Schwartz-Barcott and Kim (2000) empha- sized the importance of an empirical component in the process of theory devel- opment. To validate the Theory of Cultural Marginality with empirical data, I conducted a qualitative study exploring Korean American adolescents’ and their parents’ perceptions of being in between two different cultures. Twenty Korean American adolescents between the ages of 11 and 14 years and 21 par- ents were interviewed.

The qualitative study revealed that the main sources of stress for Korean American adolescents were managing a balanced peer relationship, discrimi- nation, pressure to excel academically and to be successful, and lack of in- depth parent–child (P–C) relationships. Parents experienced feeling uneasy and insecure about parenting children in the American culture, lacked a sense of belonging, felt ambivalent toward their children’s ethnic identity, and found they were unable to advocate for children. Parents also reported strug- gling with a lack of depth in P–C relationships (Choi & Dancy, 2009). As a result of these experiences, parents often felt inadequate, guilty, and regretful. The fi ndings were integrated into the conceptual structure of the theory. This process provides a strong empirical foundation for the Theory of Cultural Marginality. I introduce relevant quotes as I discuss the main concepts of the theory.

■ CONCEPTS OF THE THEORY

The major concepts of the Theory of Cultural Marginality are across-culture confl ict recognition, marginal living, and easing cultural tension. As an indi- vidual recognizes confl icts between cultures, he or she engages in marginal living and initiates adjustment responses to ease cultural tension. Therefore, cultural marginality is marginal living while recognizing across-culture con- fl icts and striving to ease cultural tension. An important dimension of cul- tural marginality, in addition to the major concepts, is contextual/personal infl uences that create the foundation for a person’s experience of cultural marginality. Each of the major concepts of the theory as well as contextual/ personal infl uences is discussed. In describing the major concepts of the the- ory, quotes shared by parents and adolescents in my qualitative study are shared.

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Marginal Living

Marginal living—a major concept of the theory—is defi ned as passive between- ness in the pushing/pulling tension between two cultures while forging new relationships in the midst of old and living with simultaneous confl ict/prom- ise. In the Theory of Cultural Marginality, marginal living is viewed as a pro- cess of being in between two cultures with emphasis on being in transition rather than being on the periphery of one culture.

Passive betweenness is the essential quality of marginal living. Park (1928) described the marginal experience as a situation that “condemned him to live in two worlds, in neither of which he ever quite belonged” (p. 893). Nobody chooses to be on the edge of two different cultures or to be in between. It is especially true for children who usually have no option when moving from one country to another (Guarnaccia & Lopez, 1998). They simply follow their parents’ choice of new country for a better life. Even adults who decide to live in a new country really do not want to be in an “in between” position. Some people who have experienced marginality recalled the time as “a period when they stand with both feet in different boots” (Andersson, 1995, p. 131). The experience has been described as “trapped,” “being betwixt and between,” and “being located within a structure of double ambivalence” (Bennett, 1993, p. 113; Weisberger, 1992, p. 429). The following quotes capture the quality of passive betweenness. A mother said:

I, myself, have to live a life of the crippled in this country . . . I feel like I am fl oating in the air. I don’t know if I will be able to stand on my feet before I die. I worry whether my children will grow up well . . . I know for sure that I came here for my children, but I was in agony because I thought I made a wrong decision . . . I am so worried about how to live my life as a mother.

An adolescent said:

I go crazy over . . . Korean pride and World Cup. But my friends are like, “Outside, you are Korean, but inside, you are White.” So I feel like I’m part of them. Sometimes I’m like that and sometimes I’m not.

When people move to a new country or a different culture, they inevitably must become engaged in new relationships (Rogler, 1994). New relationships do not form in a single day, and building them is not as simple as taking off old clothes and changing into new ones. One of the qualities of marginal liv- ing is forging new relationships in the midst of old relationships. This qual- ity is often more prominent among adolescents since forming new allegiances with peers and confi rming their identities and values within the peer group are critical developmental tasks. Adolescents, who are eager to forge new rela- tionships in the midst of old relationships, often encounter contradiction and confl icts. While moving forward to engage in new relationships, adolescents

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are concerned about losing connection with their old relationships. As adoles- cents actively forge new relationships while parents dwell in the past, the P–C relationship gets untied. The following quote describes the experience of an adolescent who began to engage in new relationships in a new world:

We [mom and herself] will grow apart since we will be living in two dif- ferent cultures, using different languages. I think she’s already having a hard time . . . I wish you had a program to help her overcome such barriers so we may stay close.

Adolescents who are living “in between” face tension between two cultures. Parents encourage their children to mingle with new friends, to pursue further opportunities, so that they will be successful in the new society. This phenom- enon is prominent especially among families who emigrated for better educa- tion and opportunities. However, parents feel threatened and become anxious about losing control over their children as their children blend into the new culture. The following quote illustrates the pushing/pulling quality of tension from the perspective of the father of a 12-year-old boy:

Many of their parents have double standards for them. They want their children to be successful in America as American citizens, yet they want them to remain Koreans at the same time. And that gives children an ambiguous message, which confuses them. . . . If you keep giving such contradicting messages to children, especially at a sensitive stage when they start questioning their parents’ authority, they will surely get con- fused and it might lead to creating other problems. I think that is the real problem.

Complicating matters, the new society or dominant culture has similarly contradictory attitudes toward immigrants: It welcomes immigrants warmly and promises to provide them abundant opportunities and resources; how- ever, in reality, what immigrants often face is overt and covert discrimination, as reported by both Korean American adolescents and their parents during the interviews. Korean American adolescents encountered teachers’ insensi- tive attitudes toward different cultures, experienced limited opportunities, and got unfair grades and punishments. Korean American adolescents also reported that they had been teased or bullied because of their accent and phys- ical appearance.

There is a demand for immigrants to make choices among contradicting norms, expectations, roles, and values. They often fi nd themselves struggling in simultaneous confl ict and promise. Confl ict couched in promise is a quality of marginal living causing identity confusion, anxiety, ambivalence, feelings of alienation, loss, helplessness, worthlessness, a feeling of uncertainty, and apprehension about the future (Andersson, 1995; Berry et al., 1992; Fuertes & Westbrook, 1996; Scribner, 1995; Weisberger, 1992). However, confl ict does not always create negative outcomes. Depending on how the individual perceives

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and manages confl ict, it may offer possibility for change. In a previous arti- cle on the concept of cultural marginality (Choi, 2001), confl ict and promise were categorized as two distinct attributes; however, subsequent research has indicated that promise is integral to confl ict. Thus, for the Theory of Cultural Marginality, confl ict/promise is conceptualized as a single quality of marginal living. Hall and colleagues (Hall, 1999, p. 100; Hall et al., 1994) identifi ed resil- ience and a “hope-positive view of the future” as well as vulnerabilities when marginalized people struggled to acquire their own survival strategies to pro- tect themselves and enhance their sense of well-being. Marginal living pres- ents both a confl ict and a promise as well as a crisis and a turning point, thus providing an impetus for growth.

During the interviews, Korean American parents expressed hopes for their children’s future even in the midst of feelings of alienation, powerlessness, worthlessness, and uncertainty. They expected their children to blend into mainstream society and move up the social ladder by obtaining high educa- tional status, leading children to feel pressured to excel academically and to be successful. Integral to this experience of marginal living is the recognition of across-culture confl ict, a second concept of the Theory of Cultural Marginality.

Across-Culture Confl ict Recognition

Across-culture confl ict recognition is a beginning understanding of differences between two contradicting cultural values, customs, behaviors, and norms. Just as people feel and react to perceived temperature, not measured tempera- ture, people feel and react to their recognition of differences while in between cultures. Confl ict emerges as individuals face distinct value systems with accompanying expectations and are forced to make diffi cult choices. Korean American adolescents reported encountering two distinct cultural values and expectations between peers and their parents and between Korean and American friends.

Identifying across-culture confl ict recognition as a concept of the Theory of Cultural Marginality has signifi cant implications for research and practice because it allows for individual differences in perception, responses, and men- tal health outcomes associated with cultural marginality. This is consistent with the theorizing of Lazarus (1997), who identifi ed cognitive appraisal of cultural environment as one of the signifi cant determinants of mental health outcomes. An adolescent said:

You know how parents raise their kids based on how they were raised. . . . Well, if I compare my style with regular White friends, it’s completely different. They are always out and my parents think you play too much or you do this too much but if you compare me with them, that’s not really true. Well, I know it’s best for me what they say but sometimes it’s like that’s how we live here in America.

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Easing Cultural Tension

Easing cultural tension resolves across-culture confl ict. Adjustment responses proposed in the Theory of Cultural Marginality are adapted from Weisberger’s work on marginality among German Jews (Weisberger, 1992). Four responses, assimilation, reconstructed return, poise, and integration, are processes for eas- ing cultural tension. The responses are not mutually exclusive; rather, they are mixed empirically (Weisberger, 1992) and will be referred to as response pat- terns to connote their contextual, situational, dynamic nature.

The fi rst response pattern is assimilation. It is a process whereby individuals are absorbed into the dominant or new culture (Berry, 1995; Berry & Kim, 1988; Berry et al., 1992). This is usually the fi rst response pattern exhibited by new immigrants, particularly when the dominant or new culture is unfavorable to the newcomers. Immigrants strive hard to acquire new language and customs and to mingle with people of the new society. It is a useful strategy for survival in the new culture; however, it may create self-denial, self-hatred, and feelings of guilt (Weisberger, 1992).

After encountering the new culture, individuals may return to their own cul- ture, exhibiting the pattern of reconstructed return. They may choose to return as a result of resistance, obstacles, and confl icts with a new culture or as a result of reminiscence and longing for one’s own culture. When they return, they do so with a new perspective toward their own culture as well as to the new cul- ture since they cannot be free from the infl uences of the new culture (Anderson & Levy, 2003; Weisberger, 1992). Thus, every return is a reconstructed return. A typical characteristic of people who return to or remain in their culture is an overidentifi cation with their own culture. Weisberger (1992, p. 442) describes the characteristics among the returning German Jews as “more Jewish than Jewish.” The following quote is from a mother of a 14-year-old daughter who was referred by her teacher to a school counselor for her misbehavior at school:

Even if she was born here [United States] and has never been to Korea, she always hangs out with Korean friends, particularly Korean kids who recently moved from Korea. She likes to have Korean clothes, accessories, phone, and stuff . . . I think it is because [of] her longing for Korea and Korean culture.

Poise is a response pattern characterized by a tentative fi t on the margin regardless of emotional confl ict and struggle. Individuals who respond with poise may become free from obligation or attachment to a certain culture, but they have to be “homeless in a cultural sense” (Weisberger, 1992, p. 440). Even when responding with a pattern of poise, individuals will continue to experi- ence emotional confl icts and a period of personal crisis continues. Accumulated effects of crisis may include stress and poor mental health outcomes such as personality changes, substance abuse, depression, and even suicidal ideation (Hovey & Magana, 2002; Park, 1928; Vega et al., 1998; Williams & Berry, 1991).

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Integration is an adjustment response pattern where an individual creates a third culture by merging and integrating the old and new cultures. Through integration, individuals surpass cultural boundaries, contexts, and identities and acquire superior social functioning, gaining access to multiple cultural worlds (Guarnaccia & Lopez, 1998; Park, 1928; Weisberger, 1992) and eas- ing cultural tension. They will experience a sense of cultural home, a sense of belonging, integration of identity, and psychological and cognitive growth (Bennett, 1993; Vivero & Jenkins, 1999). For them, the possibility of return- ing to the cultural tension of marginal living is minimized. When faced with another circumstance of cultural tension, it is likely that they will respond suc- cessfully. The level of ease experienced during the process will infl uence the mental health and well-being of the individual. A 14-year-old boy who used to struggle to fi t in with peers due to language and cultural barriers now becomes comfortable with both American and Korean cultures and feels confi dent:

I feel very special in a positive way. There are my friends who think I’m cool. They rather look UP to me . . . I explain to my friends what Korean culture is. Like New Year’s Day, they called me to go with them and watch fi reworks. I was like, “I can’t” and I explained to them what “Duk-gook” [Korean traditional food] is and “Sae-bae.” Like I have to bow down and I get money. And they are like, “Can we come to your house and do ‘Sae- bae’ so we get money too?” I explained to them and they want to know more about it. One of my friends can actually count from 1 to like 25. They actually go to Web sites so they can learn, so they can talk to me. And I actually gave them Korean music, and he’s like, can you type the lyrics in English? So they are more into Koreanness. They are more interested.

One adjustment response pattern may have more constructive impact on an individual’s mental health than the others; however, there is no ideal or most useful pattern that works for everyone, nor is there one pattern that works for one person all of the time. For instance, integration may be a feasible adjust- ment response pattern for immigrant adolescents but not for immigrant older adults. For older adults, remaining in contact with the old culture and returning to old-culture ways may make them more comfortable; the pattern of recon- structed return may be most useful for them. For healthcare providers working with immigrant populations, it is important to assess unique experiences and perceptions rather than to categorize individuals based on their adjustment response pattern. However, knowledge about the response patterns individu- als use to ease cultural tension may enable understanding of the complex pro- cesses that are central to the struggle that many immigrants face.

Contextual/Personal Infl uences

Scholars of Acculturation Theory recognize nature or types of the dominant society and characteristics of acculturating individuals as signifi cant factors in

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the acculturation process (Berry & Kim, 1988; Williams & Berry, 1991). In this Theory of Cultural Marginality, the factors infl uencing the process of across- culture confl ict recognition, marginal living, and easing cultural tensions are described as contextual/personal infl uences.

Contextual infl uences identifi ed in literature reviews and shared in inter- views with Korean Americans are the nature of the dominant society, such as openness or tolerance to diversity, available social and healthcare resources for immigrants, racial and/or ethnic composition of school and neighborhood, and support from teachers and peers. Particularly, healthcare providers’ beliefs and attitudes toward an individual from a different cultural background play a signifi cant role in this model since their beliefs and attitudes could result in undesirable ethical consequences of patient care as well as inappropriate care (Johnstone, 2016).

The personal infl uences include the knowledge about the dominant society, age at immigration, length of stay in the dominant society, educational back- grounds, socioeconomic status, language profi ciency, ethnic identity, preimmi- gration experiences, reasons for immigration, loyalty to own culture, resilience, or ability to endure the hardship, openness, P–C relationships, coping strate- gies, and signifi cant others’ attitude toward the dominant culture (Berry, 1995; Berry & Kim, 1988; Berry et al., 1992; Trueba, 2002).

These infl uences govern not only the individuals who are in the midst of cultural marginality but also the dominant culture that is a source of interaction for immigrant people. Existing theories describing accultura- tion have been criticized for ignoring the infl uences of the acculturating individuals or groups to the dominant culture (Rudmin, 2003). The theories viewed acculturating individuals only as passive recipients. When two cul- tures clash, the interaction is reciprocal although the strength of the infl u- ence may not be comparable. Contextual/personal infl uences make the interaction between two cultures and the effect of one culture on another a mutual process.

■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL

Figure 14.1 depicts the relationships among the major concepts of the theory. Marginal living begins with the recognition of across-culture confl ict.

As individuals encounter marginal living, they strive to ease cultural ten- sion through adjustment response patterns. The four response patterns are assimilation, reconstructed return, poise, and integration. Although not an explicit concept in the theory, the importance of contextual/personal infl u- ences is recognized by inclusion as a foundation for the Theory of Cultural Marginality.

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■ USE OF THE THEORY IN NURSING RESEARCH AND EDUCATION

The concept of cultural marginality (Choi, 2001) and the Theory of Cultural Marginality (Choi, 2008) have been cited in various areas of nursing research and practice (Alexander, Kinman, Miller, & Patrick, 2003; Buscemi, 2011; Horback & Rothery-Jackson, 2007; Loue & Sajatovic, 2012). The concept was used to understand experiences of Mexican American families caring for chil- dren with serious chronic conditions (Rehm, 2003), analyze the concept of acculturation in Mexican immigrants (Page, 2006), study the stress experienced by Pakistani Ismaili Muslim girls (Khuwaja, Selwyn, Kapadia, McCurdy, & Khuwaja, 2007), and explore the cultural identity of Afro-Caribbean Americans (Archibald, 2011).

Since the theory was introduced, it has been used to guide research and practice for people experiencing marginal living. First, based on the Social Cognitive Theory and Cultural Marginality Theory, I developed an individually administered, computer-based mental health promotion program, Promoting Intergenerational Dialogue on Emotions (PRIDE). (Note: The program name was changed from “Be Connected” to PRIDE; Choi, 2012.) Using a two-group,

Marginal Living

Negotiation

Assimilation Reconstructed

Return

Integration

Culture of Origin

New Culture

Contextual/Personal Influences

Easing Cultural Tension

Across-Culture Conflict Recognition

Poise

FIGURE 14.1 Cultural Marginality.

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repeated-measures, and controlled randomized study design, I tested the fea- sibility of PRIDE and compared the effi cacy of PRIDE with an attention control (AC) group on parental knowledge, parental stress, parental self-effi cacy, fi lial self-effi cacy, P–C communication, P–C confl ict, and P–C satisfaction. A total of 58 parents (28 fathers and 30 mothers) and 30 Korean American adolescents aged 11 to 14 years participated in the study (16 families in PRIDE and 14 fami- lies in the AC group). PRIDE had good feasibility for Korean American fami- lies and was favored by both parents and adolescents. Effi cacy results of the study were also promising at 1 month postintervention. Particularly, fathers’ parental knowledge (d = 0.82), mothers’ parental knowledge (d = 1.95), fathers’ report on P–C communication (d = 0.61), and Korean American adolescents’ report on confl icts with the father (d = 0.44) showed medium-to-large effects of PRIDE compared with an AC condition. As PRIDE is taken to a larger trial, this computer-based program may then be disseminated to multicity commu- nity settings. The development and pilot testing of PRIDE is reported in detail elsewhere (Choi, 2012).

A second area of research for the Theory of Cultural Marginality is instrument development. Researchers have developed scales to measure levels of accul- turation and acculturative stress and to explain the relationships between these concepts and mental health outcomes (Hovey & King, 1997; Padilla, Alvarez, & Lindholm, 1986; Phinney, 1992; Sam & Berry, 1995; Williams & Berry, 1991). In addition, cultural competence has been studied and I have collaborated with a team of researchers to develop a Korean version of the Cultural Awareness Scale (K-CAS; Choi, Suh, Park, Park, & Hernandez, 2015) with good reliabil- ity (alpha = .83) and construct validity. However, there is no scale specifi cally designed to measure cultural marginality.

The phenomenon of globalization is not limited to the United States. As of 2015, about 1.90 million foreigners (3.9% of total population) reside in Korea and about 8% of them (151,608) immigrated to Korea for marriage (Korean Immigration Service, 2015). Currently, about 278,036 interracial families live in Korea and 207,693 children are growing up in interracial families (Ministry of Gender Equality and Family, 2016). To assess marginal living experiences of immigrant children living in South Korea, including biracial children, I devel- oped the cultural marginality scale.

The items on this 13-item scale were derived from the qualitative descrip- tive study of Korean American adolescents and their parents and the existing acculturative stress scale, the Societal, Attitudinal, Familial, and Environmental Acculturative Stress Scale for Children (SAFE-C; Chavez et al., 1997). Responses range from 0 = hardly ever or never to 3 = almost always. As a next step in devel- oping a reliable and valid instrument, I conducted cognitive interviews with nine children, aged 10 to 13. The main purpose of the cognitive interview was to explore the cognitive processes that respondents use to answer the ques- tions (i.e., how respondents understand, mentally process, and respond to the

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questions; Knafl et al., 2007; Willis, 2005). The cognitive interview helps the researcher clarify intention of questions and identify problems with wording, readability, item or section sequence, and length of the instrument. The cog- nitive interview is generally conducted with a small number of respondents (5–25 people) before fi eld-testing a newly developed instrument.

All participants were born in interracial families; self-identify themselves as having multiple cultural identities or heritages; and currently reside in Korea. Seven out of nine children reported that one of their parents was from China. One child reported having an Indonesian mother and another child reported having a Japanese mother.

During the cognitive interviews, any diffi cult or confusing words were iden- tifi ed and rephrased to increase clarity and reduce possible errors in responses. The 13-item cultural marginality scale assessing children’s experiences of marginal living was fi nalized based on the fi ndings of the interviews. These 13 items generally address topics like ethnic identity, peer relationship prob- lems, and perceived discrimination. Example items with this specifi c sample include: I don’t feel like I am Korean or Chinese; My parents want me to under- stand and remember their respective cultures; I think that kids don’t want to play with me because of my mixed background; and I think that being raised in interracial families could be my unique strength. Psychometric testing will occur for the Korean version of this instrument before proceeding with transla- tion and testing in an English-speaking population.

The cultural marginality scale with items aligned according to the concepts of the theory will allow assessment of the structure of the associated concepts and of the extent to which cultural marginality infl uences health. Assessing the relationship between cultural marginality and mental health outcomes has signifi cant implications for the healthcare of immigrants. It has particu- lar relevance for preventive care, where nurses caring for immigrants develop approaches for recognizing those who are at risk for mental health problems.

An education research project guided by the Theory of Cultural Marginality was the study titled Cultural Competency Among Nursing. This was the study that enabled testing of the K-CAS (Choi et al., 2015). One of the most critical contextual infl uences affecting an individual’s experience of cultural marginal- ity is the nurse’s openness to diversity and competency in caring for patients from diverse sociocultural backgrounds. The specifi c aims of this mixed- method study were to (a) assess perceived levels of openness to diversity and cultural competence among Korean nursing students; (b) explore Korean nursing students’ nursing care experiences with patients from diverse cultural backgrounds; and (c) explore Korean nursing students’ needs for cultural com- petence education integrated into the nursing curriculum. The ultimate goal of the study was to develop a nursing curriculum that would prepare students for a culturally diverse patient population in Korea. A total of 515 nursing students (364 undergraduate and 151 graduate students) from four nursing

312 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

schools in Korea completed the questionnaire. Additionally, 18 undergraduate and 20 graduate students (n = 38) participated in one of six focus groups.

The study indicated a lack of understanding of the concept of cultural com- petence among Korean nursing students (Choi et al., 2015). In addition, the fi ndings from the qualitative data demonstrated that participants encoun- tered their personal boundaries regarding openness to other cultures and they experienced prejudice when caring for ethnically diverse patients. The fi ndings confi rmed that the interaction between two cultures is reciprocal and that healthcare providers and patients were mutually infl uenced by each other.

The fi ndings were incorporated into a nursing course called “Sociocultural diversity and health.” The objective of this course was to help students under- stand the infl uence of various cultures (e.g., racial, ethnic, socioeconomic, edu- cational, and geographic) on healthcare services and research.

The study conducted by Cardona (2016) is the most recent work guided by the Theory of Cultural Marginality. Cardona used the theory to develop a culturally relevant eating disorder assessment tool for Hispanic women and identify healthcare providers’ behaviors that could promote culturally relevant interactions with these women. Even though it was a pilot study, conducted with fi ve Hispanic women who were diagnosed with eating disorders, it dem- onstrated that the women had experienced feelings of alienation while dealing with symptoms of their eating disorders (e.g., dietary restrictions, weight fl uc- tuations) infl uenced by both American and Hispanic cultures.

■ USE OF THE THEORY IN NURSING PRACTICE

Previously, the concept of cultural marginality has been used to discuss adher- ence issues of Mexican clients (Barron, Hunter, Mayo, & Willoughby, 2004) and to address the gap in healthcare provider–client relationships and its impact on health disparities. The theory can also be applied to school nurse practice to foster awareness of culturally distinct adolescent needs (Labun, 2003).

Another example of use of the theory in nursing practice is the application of it to the case of a 23-year-old, English-speaking African refugee to the United States (Burke, 2011). At the age of 13, she experienced the most severe type of female genital mutilation (FGM) by an elder in Djibouti, Africa, and suffers from candidiasis and hematocolpos. In her article, Burke analyzed experiences of the patient using the concepts of the theory and discussed how the Theory of Cultural Marginality can be used as a framework to guide culturally sensitive, evidence-based nursing care for women with FGM. Particularly, she empha- sized the need for nurses to constantly assess contextual and personal infl u- ence factors, to serve as a signifi cant contextual infl uence, to provide culturally relevant care, and to support patients’ integration of cultures while assisting with health decisions.

14 . THEORY OF CULTURAL MARG INAL I TY  313

Use of the theory in practice is limited; however, the aforementioned exam- ples of research and practice demonstrate possible applications for the Theory of Cultural Marginality. Possible areas include education or health promotion programs assessing and modifying an individual’s personal infl uences, cultur- ally relevant therapeutic nurse–patient interactions, and development of cul- tural competence training for healthcare providers.

In this chapter, the Theory of Cultural Marginality was described mainly in the context of immigrant adolescents’ experiences; however, the theory is applicable to any immigrant who is encountering marginal living. The Theory of Cultural Marginality can be used as a framework to explore unique experi- ences of diverse groups of immigrants and people caught between two distinct cultures and to provide care for them. Particularly, recognizing the infl uence of the contextual/personal factors has signifi cant implications for healthcare providers. For instance, adjustment response patterns and healthcare needs among immigrants who came to a new country for freedom cannot be the same as those for people who immigrated for educational opportunities. By recog- nizing these infl uences and modifying them when appropriate, healthcare pro- viders may ease the adjustment process, promote healthy development, and elicit desirable health outcomes.

■ CONCLUSION

What is it like to be caught between cultures? How does that experience impact one’s health? How can healthcare providers ease the experience? These questions have inspired the development of the Theory of Cultural Marginality. The goal of the theory is to highlight the complexity of living between two cultures by empha- sizing the challenge to the health of people encountering marginal living, and thereby, enlighten healthcare providers to provide appropriate care for them. The theory elucidates essences of marginal living, across-culture confl ict recognition, and striving to ease cultural tension while recognizing the fundamental impor- tance of contextual/personal infl uences. Understanding of the theory and the relationships among the concepts promises a framework for culturally relevant healthcare for immigrant people. Nowadays, health issues related to immigra- tion affect many different countries. To better meet the needs of the increasingly diverse groups of people (e.g., children from interracial families, third-culture individuals), the theory needs to continuously evolve and be refi ned through fur- ther research and practice within and outside the United States.

■ REFERENCES

Alexander, G. L., Kinman, E. L., Miller, L. C., & Patrick, T. B. (2003). Marginalization

and health geomatics. Journal of Biomedical Informatics, 36, 400–407.

314 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Anderson, T. L., & Levy, J. A. (2003). Marginality among older injectors in

today’s illicit drug culture: Assessing the impact of ageing. Addiction, 98,

761–770.

Andersson, E. P. (1995). Marginality: Concept or reality in nursing education? Journal of Advanced Nursing, 21, 131–136.

Archibald, C. (2011). Cultural tailoring for an Afro-Caribbean community: A

naturalistic approach. Journal of Cultural Diversity, 18(4), 114–119.

Barron, F., Hunter, A., Mayo, R., & Willoughby, B. (2004). Acculturation and

adherence: Issues for health care providers working with clients of Mexican

origin. Journal of Transcultural Nursing, 15, 331–337.

Bennett, J. M. (1993). Cultural marginality: Identity issues in intercultural training.

In R. M. Paise (Ed.), Education for intercultural experience (pp. 109–135). Yarmouth,

ME: Intercultural Press.

Berry, J. W. (1995). Psychology of acculturation. In N. R. Goldberger & J. B. Veroff

(Eds.), The culture and psychology reader (pp. 457–488). New York: New York

University.

Berry, J. W., & Kim, U. (1988). Acculturation and mental health. In P. R. Dasen, J. W.

Berry, & N. Sartorius (Eds.), Health and cross-cultural psychology: Toward applications

(pp. 207–236). Newbury Park, CA: Sage.

Berry, J. W., Poortinga, Y. H., Segall, M. H., & Dasen, P. R. (1992). Cross-cultural psychology: Research and applications. New York, NY: Cambridge University.

Burke, E. (2011). Female genital mutilation: Applications of nursing theory for clinical

care. The Nurse Practitioner, 36, 45–50.

Buscemi, C. P. (2011). Acculturation: State of the science in nursing. Journal of Cultural Diversity, 18(2), 39–42.

Cardona, G. R. (2016). Initial testing of the risk assessment of eating disorders (RAED) tool for use in primary care of Hispanic women (Unpublished doctoral dissertation).

University of Arizona, Tuscon, Arizona.

Chavez, D. V., Moran, V. R., Reid, S. L., & Lopez, M. (1997). Acculturative stress in

children: A modifi cation of the SAFE Scale. Hispanic Journal of Behavioral Sciences,

19, 34–44.

Choi, H. (2001). Cultural marginality: A concept analysis with implications

for immigrant adolescents. Issues in Comprehensive Pediatric Nursing, 24,

193–206.

Choi, H. (2008). Theory of cultural marginality. In M. J. Smith & P. R. Liehr (Eds.),

Middle range theory for nursing (2nd ed., pp. 243–260). New York, NY: Springer

Publishing.

Choi, H. (2012). The development of a culturally relevant preventive intervention.

Open Journal of Nursing, 2, 123–129.

Choi, H., & Dancy, B. L. (2009). Korean American adolescents’ and their parents’

perceptions of acculturative stress. Journal of Child and Adolescent Psychiatric Nursing, 22, 203–210.

Choi, H., Meininger, J. C., & Roberts, R. E. (2006). Ethnic differences in adolescents’

mental distress, social stress, and resources. Adolescence, 41(162), 263–283.

14 . THEORY OF CULTURAL MARG INAL I TY  315

Choi, H., Suh, E. E., Park, C., Park. J., & Fernandez, E. (2015). Reliability and validity

of a Korean version of the Cultural Awareness Scale (K-CAS). Korean Journal of Adult Nursing, 27(4), 472–479.

Choi, H., Stafford, L., Meininger, J. C., Roberts, R. E., & Smith, D. P. (2002).

Psychometric properties of the DSM Scale for Depression (DSD) with Korean

American youths. Issues in Mental Health Nursing, 23, 735–756.

Del Pilar, J. A., & Udasco, J. O. (2004). Marginality theory: The lack of construct

validity. Hispanic Journal of Behavioral Sciences, 26, 3–15.

Fuertes, J. N., & Westbrook, F. D. (1996). Using the Social, Attitudinal, Familial,

and Environmental (SAFE) Acculturation stress scale to assess the adjustment

needs of Hispanic college students. Measurement and Evaluation in Counseling and Development, 29, 67–76.

Gil, A. G., Wagner, E. F., & Vega, W. A. (2000). Acculturation, familism, and alcohol

use among Latino adolescent males: Longitudinal relations. Journal of Community Psychology, 28, 443–458.

Guarnaccia, P. J., & Lopez, S. (1998). The mental health and adjustment of immigrant

and refugee children. The Child Psychiatrist in the Community, 7, 537–553.

Hall, J. M. (1999). Marginalization revisited: Critical, postmodern, and liberation

perspectives. Advances in Nursing Science, 22(2), 88–102.

Hall, J. M., Stevens, P. E., & Meleis, A. I. (1994). Marginalization: A guiding concept

for valuing diversity in nursing knowledge development. Advances in Nursing Science, 16(4), 23–41.

Horback, S., & Rothery-Jackson, C. (2007). Cultural marginality: Exploration of

self-esteem and cross cultural adaptation of the marginalized individual: An

investigation of the second generation Hare Krishnas. Journal of Intercultural Communication, 14. Retrieved from https://www.immi.se/intercultural/nr14/

horback.htm

Hovey, J. D., & King, C. A. (1997). Suicidality among acculturating Mexican

Americans: Current knowledge and directions for research. Suicide and Life- Threatening Behavior, 27, 92–103.

Hovey, J. D., & Magana, C. G. (2002). Exploring the mental health Mexican migrant

farm workers in the midwest: Psychosocial predictors of psychological distress

and suggestions for prevention and treatment. Journal of Psychology, 136,

493–513.

Im, E.-O., & Lipson, J. G. (1997). Menopausal transition of Korean immigrant women:

A literature review. Health Care for Women International, 18, 507–520.

Johnstone, M.-J. (2016). Bioethics: A nursing perspective (6th ed.). Chatswood, Australia:

Elsevier.

Keefe, S. E., & Padilla, A. M. (1987). Chicano ethnicity. Albuquerque: University of

New Mexico Press.

Khuwaja, S. A., Selwyn, B. J., Kapadia, A., McCurdy, S., & Khuwaja, A. (2007).

Pakistani Ismaili Muslim adolescent females living in the United States of

America: Stresses associated with the process of adaptation to U.S. culture.

Journal of Immigrant Health, 9, 35–42.

316 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

Knafl , K., Deatrick, J., Gallo, A., Holcombe, G., Bakitas, M., Dixon, J., & Grey, M.

(2007). The analysis and interpretation of cognitive interviews for Instrument

development. Research in Nursing and Health, 30, 224–234.

Korean Immigration Service. (2015). Korean immigrant service statistics. Retrieved

from https://www.immigration.go.kr/HP/COM/bbs_003/ListShowData.do?str

NbodCd=noti0096&strWrtNo=129&strAnsNo=A&strOrgGbnCd=104000&strRtn

URL=IMM_6050&strAllOrgYn=N&strThisPage=1&strFilePath=imm

Labun, E. (2003). Working with a Vietnamese adolescent. Journal of School Nursing, 19,

319–325.

Lazarus, R. S. (1997). Acculturation isn’t everything. Applied Psychology, 46, 39–43.

Loue, S., & Sajatovic, M. (Eds.). (2012). Encyclopedia of immigrant health. New York,

NY: Springer Publishing.

Migration Policy Institute. (2017). State immigration data profi les. Retrieved from

http://www.migrationpolicy.org/data/state-profi les/state/demographics/US

Ministry of Gender Equality and Family. (2016). 2015 National Multicultural Family Survey (Report 2016-03). Seoul, South Korea: Hanhak Munhwa.

Noh, S., & Kaspar, V. (2003). Perceived discrimination and depression: Moderating

effects of coping, acculturation, and ethnic support. American Journal of Public Health, 93, 232–238.

Oetting, E. R., & Beauvais, F. (1990–1991). Orthogonal cultural identifi cation theory:

The cultural identifi cation of minority adolescents. The International Journal of the Addictions, 25, 655–685.

Padilla, A. M., Alvarez, M., & Lindholm, K. J. (1986). Generational status and

personality factors as predictors of stress in students. Hispanic Journal of Behavioral Sciences, 8, 275–288.

Page, R. L. (2006). Acculturation in Mexican immigrants: A concept analysis. Journal of Holistic Nursing, 24(4), 270–278.

Park, R. E. (1928). Human migration and the marginal man. The American Journal of Sociology, 33, 881–893.

Phinney, J. S. (1992). The multigroup ethnic identity measure: A new scale for use

with adolescents and youth adults from diverse groups. Journal of Adolescent Research, 7, 156–176.

Redfi eld, R., Linton, R., & Herskovits, M. J. (1936). Memorandum on the study of

acculturation. American Anthropologist, 38, 149–152.

Rehm, R. S. (2003). Legal, fi nancial, and ethical ambiguities for Mexican American

families: Caring for children with chronic conditions. Qualitative Health Research,

13, 689–702.

Rogler, L. H. (1994). International migrations: A framework for directing research.

American Psychologist, 49, 701–708.

Rudmin, F. W. (2003). Critical history of the acculturation psychology of assimilation,

separation, integration, and marginalization. Review of General Psychology, 7, 3–37.

Sam, D. L., & Berry, J. W. (1995). Acculturative stress among young immigrants in

Norway. Scandinavian Journal of Psychology, 36, 10–24.

Schwartz-Barcott, D., & Kim, H. S. (2000). An expansion and elaboration of the hybrid

model of concept development. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing (2nd ed., pp. 129–159). Philadelphia, PA: Saunders.

14 . THEORY OF CULTURAL MARG INAL I TY  317

Scribner, A. P. (1995). Advocating for Hispanic high school students: Research-based

educational practices. The High School Journal, 78, 206–214.

Stonequist, E. V. (1935). The problem of the marginal man. The American Journal of Sociology, 41, 1–12.

Trueba, H. T. (2002). Multiple ethnic, racial, and cultural identities in action: From

marginality to a new cultural capital in modern society. Journal of Latinos and Education, 1, 7–28.

Vega, W. A., Gil, A. G., & Wagner, E. (1998). Cultural adjustment and Hispanic

adolescent drug use. In W. A. Vega & A. G. Gil (Eds.), Drug use and ethnicity in early adolescence (pp. 125–148). New York, NY: Plenum.

Vivero, V. N., & Jenkins, S. R. (1999). Existential hazards of the multicultural

individual: Defi ning and understanding “cultural homelessness.” Cultural Diversity and Ethnic Minority Psychology, 5, 6–26.

Weisberger, A. (1992). Marginality and its directions. Sociological Forum, 7, 425–446.

Williams, C. L., & Berry, J. W. (1991). Primary prevention of acculturative stress

among refugees: Application of psychological theory and practice. American Psychologist, 46, 632–641.

Willis, G. B. (2005). Cognitive interviewing. Thousand Oaks, CA: Sage.

Ziller, R. C. (1973). The social self. New York, NY: Pergamon.