*3.1. "We Want to Earn Money to Improve the Living Conditions of Our Family": The Migratory Adventure*

A total of 252 businesses and institutions were visited and 133 Chinese immigrants agreed to participate. The sample included only Chinese immigrants and consisted of 61.7% women and 38.3% men, with a mean age of 30.7 years (ranging from 18 years to 55 years old), and an average length of residence in Spain of 11.3 years. More details about the participants are shown in Table 2.


**Table 2.** Sample characteristics.

The sociodemographic characteristics of the participants reveal that most of them come from the Zhejiang province. Zhejiang is a rural geographical area, with few job and economic opportunities for its inhabitants, especially for those with a lower educational level. This is the main reason why Chinese families with low qualifications among their members decide to emigrate. Given that migration for economic reasons is unanimous, immigrants tend to share this decision with other family members. The immigration usually works in the following way: one of the marriage partners emigrates alone and provides economic support to their family in China, waiting until the whole family (including children) is able to emigrate to Spain. Most immigrants use airport transportation to travel to Spain, which does not initially imply risks to their health.

The migration experience of their peers allows Chinese immigrants to search within their community for a support network that makes migration and adaptation to the destination a more comfortable and easier process. Social relations between Chinese people

allows for offering work within the same ethnic niche, the maintenance of the original language, and sharing the same culinary customs, among others. From the statements of the participants, the most important milestones associated with the migratory process are shown in Figure 1.

The migration experience of their peers allows Chinese immigrants to search within

allows for offering work within the same ethnic niche, the maintenance of the original

economic opportunities for its inhabitants, especially for those with a lower educational level. This is the main reason why Chinese families with low qualifications among their members decide to emigrate. Given that migration for economic reasons is unanimous, immigrants tend to share this decision with other family members. The immigration usually works in the following way: one of the marriage partners emigrates alone and provides economic support to their family in China, waiting until the whole family (including children) is able to emigrate to Spain. Most immigrants use airport transportation to travel

From the statements of the participants, the most important milestones associated with the migratory process are shown in Figure 1. "To retu rn

**Figure 1.** Milestones associated with the Chinese migratory process.

#### *3.2. Berry's Model of Acculturation and Health*

*Int. J. Environ. Res. Public Health* **2021**, *18*, x 7 of 15

to Spain, which does not initially imply risks to their health.

language, and sharing the same culinary customs, among others.

**Figure 1.** Milestones associated with the Chinese migratory process. *3.2. Berry's Model of Acculturation and Health* As a result of the acculturation process, social and health behaviors were analyzed under the perspective of Berry's Model. In the present study, two main themes ("*Social*  As a result of the acculturation process, social and health behaviors were analyzed under the perspective of Berry's Model. In the present study, two main themes ("*Social Relations"* and *"Health Lifestyles"*) and five domains ("*Values and need: Social relations among Chinese", "Experiences within Spanish society", "Food pattern", Physical Activity",* and *"Tobacco and alcohol"*) were retrieved and are described below.

#### *Relations"* and *"Health Lifestyles"*) and five domains ("*Values and need: Social relations among*  3.2.1. Theme: Social Relations

*Chinese", "Experiences within Spanish society", "Food pattern", Physical Activity",* and *"Tobacco and alcohol"*) were retrieved and are described below. 1. Domain: Values and need: Social relations among Chinese

3.2.1. Theme: Social Relations 1. Domain: Values and need: Social relations among Chinese In our analysis, cultural separation is the most used strategy for social relationships among Chinese immigrant community members, since they respond affirmatively to maintaining strong ties with the group of origin, while contact with people of the new culture is still scarce. This seems to be partially explained by one of the fundamental pil-In our analysis, cultural separation is the most used strategy for social relationships among Chinese immigrant community members, since they respond affirmatively to maintaining strong ties with the group of origin, while contact with people of the new culture is still scarce. This seems to be partially explained by one of the fundamental pillars of the Confucian Chinese philosophy, which is the value given to the family. To these participants, Chinese society is understood as a "large family", with hierarchical standards of respect and courtesy towards important family members.

lars of the Confucian Chinese philosophy, which is the value given to the family. To these *"There is the concept of guanxi, so reputation is very important (...). A Chinese who only ¯ knows another Chinese twice and invites him to the wedding* . . . *he is almost obliged to go, because if he refuses, the community will judge this act inappropriate and consequences may arise"* (C-48 man, 40 years).

In addition to these values, the degree and quantity of social relations among Chinese individuals is not an option, but rather an imperative aiming to guarantee support and resources within the community and, for this reason, assimilation or marginalization strategies seem to have no place:

*"The range of social relations that a Chinese has is very large (* . . . *) the more friends you have at all levels of society, the better, because Chinese society works like this"* (C-78 woman, 22 years).

Likewise, Chinese immigrants usually need support from other Chinese immigrants in order to be able to settle in the destination cities upon arrival in Spain:

*"They offer housing, food and they help other Chinese to find a job (...). It is not enough when you want to start your own business, so your cousins, your brothers, everyone helps you"* (C-21 man, 30 years)*; "The support is fundamentally financial and it comes from the family, friends and acquaintances, they do not usually request external financing. Furthermore, this is done without any claim to profit (...). It is a society in which commitment and loyalty are highly taken into account and everyone knows that favors will be returned"* (C-94 woman, 41 years).

Having secured financing is very important for them in the decision to emigrate and also to work for others and then open their own business, which is their ultimate goal. This reflects that relations with the ethnic group are not temporary, but are maintained over time, since those who one day received help will help others in the future.

#### 2. Domain: Experiences within Spanish society

Chinese immigrants perceive prejudices from Spanish population:

*"People [Spanish people] say that we are invading, we are stealing their jobs, we do not pay taxes; that's a lie!"* (C-120 man, 19 years).

The lack of cultural integration with the Spanish population seems to have deleterious effects to the Chinese community, which has difficulties in understanding the host culture and tends to reject contact with those who judge them in this negative way.

It seems that community support alleviates the psychological discomfort of being exposed to constant prejudice. In this respect, most participants reported that they were satisfied with their current life in Spain, and highlighted positive aspects such as the emotional support received by their peers, having people who care about them, receiving love and affection, being able to talk about their problems, receiving useful advice, and receiving invitations to go out.

Anther barrier for social relations with the Spanish population is the language, as noted below:

*"If you do not know the language, you are secluded (...), and if you are working in an environment in which you use the language minimally, you do not learn it"* (C-35 woman, 19 years)*; "They have a hard time learning Spanish. I have been Spanish teacher for adult Chinese for more than 10 years, but there is no way they can learn it well"* (C-127 woman, 44 years).

*"I always tell parents that they should bring their children before, when they are little. It is very difficult to learn a new and so different language when the child is 12 years old (* . . . *). I think that when they are small, they are abandoned in China, and when they grow up, they are abandoned by society"* (C-72 woman, 43 years).

Finally, work seems to be a key factor in initiating ties with the Spanish population, since relationships are "forced" because Chinese immigrants need to attend to customers in their businesses. In the case of younger Chinese individuals, this relationships tend to be stronger due to their school friends.

*"I believe that Chinese immigrants make relationships, especially among the Chinese members, united by the labor issue and with their family. Although, they can also make any relationship with a Spanish person through work, or a family member, there are people who do not have good experience and feel indifferent and protect themselves in their own community. But then, there are other people and there are more and more young Chinese who have been born here, who go to schools. In short, in 15–20 years this will change a lot"* (C-40 man, 53 years).

3.2.2. Theme: Health Lifestyles

1. Domain: Food patterns

There is a clear barrier concerning Chinese immigrants to abandon their culinary habits of origin or to incorporate at least in part the Spanish cuisine.

*"The food is totally Chinese from the beginning of the day. We usually have boiled rice or noodle soup for breakfast"* (C-88 man, 35 years).

Their basic diet is characterized by the use of many dishes with varied products, the daily consumption of rice or noodles as the main source of carbohydrates, the consumption of vegetables, as well as the frequent consumption of meat, fish, and eggs, with different ways of cooking (wok or dehydration) as compared to the Western tradition. All these products are available in Spanish supermarkets and in other specialized markets owned by the Chinese community.

Food cultural separation is clearly supported when healthier characteristics are attributed to the Chinese diet compared to the Western one, such as the regulatory capacity of foods to ensure the balance between cold and heat and the "yin and yang" associated with Traditional Chinese Medicine (TCM). Another factor related to the maintenance of these customs is the presence of many typical dishes associated with festivals of Chinese culture and the attribution of properties such as luck.

Something observed during the study was that as the time living in Spain increases, Chinese immigrants tend to further integrate Western foods (mainly toast, cereals, or coffee with milk) into their meals such as breakfast. There are a greater number of Chinese younger individuals eating the Western breakfast, since this is more practical and fast in their view:

*"I usually have Spanish breakfast, milk with cereals, since I work very early and I don't have time to prepare an authentic Chinese breakfast. To do this it would need at least an hour [to cook the rice soup and eat it]"* (C-63 woman, 22 years).

Western fast food and fat consumption is also more prevalent among young people and is even provided to young children by their parents in business. These signs of cultural integration are also manifested in the adherence to the Western body worship and beauty, which affects diets carried out by women and young people, the former restricting certain foods to lose weight, and the latter incorporating hyperprotein diets that support the physical activity performed in gyms.

Despite the fact that Chinese immigrants are incorporating some Western foods, all participants reported that they still prefer their original Chinese food:

*"We can go to a Spanish restaurant one day and eat tapas, but not daily"* (C-36 man, 37 years).

#### 2. Domain: Physical activity

Although the practice of regular exercise in parks and squares in China is common, this is not maintained by Chinese immigrants living in Spain. Likewise, the choice of exercise by participants is minimally influenced by the traditional Chinese culture and, for this reason, the group practice of GuangBo TiCao (group exercise characterized by collectivity, discipline and conformity), tai chi, Yuanji dance, and kung fu are not very common in Spain. The scarce physical activity carried out by this group also does not maintain many similarities with the practice of the Spanish population, and is mainly related to the lack of time due to the intensity of their working day:

*"Sometimes I ran 3 or 4 times a week at night, but now between the store and the girl, I can't do it much"* (C-43 woman, 36 years).

The Chinese immigrants' concerns on their job and the work overload decrease the importance of physical activity as a source of physical well-being. In addition, Chinese consider themselves to be physically active during their working day, reporting that they practice a lot of exercise during the tasks they perform in their jobs.

*"Intense physical activity is what I do for 3 h, once a week when I unload the truck with the merchandise. In addition, all week I have moderate activity when I have to go shopping at the stores to replenish the daily basic merchandise"* (C-5 man, 43 years).

As a result of acculturation, young people are again those who show a greater integration of habits related to physical activity and sport. It is common for young people to use the gyms and perform more intense physical activities such as weight-lifting.

*"I think most of the young people go to gyms and play sports, but most adults do not practice any physical activity (...). If they leave in the morning and return at night and also have family responsibilities ... no"* (C-44 man, 26 years).

3. Domain: Tobacco and alcohol

Chinese immigrants consider smoking as a social behavior, particularly for men: (KI-5) "*The idea of them is that to do business you have to smoke and drink*", and they believe Chinese individuals have a greater consumption compared to the Western population. Although most smokers maintain a consumption of more than one pack of cigarettes a day, they are forced to obey certain Spanish legal regulations, such as the prohibition of smoking inside establishments. Nevertheless, some establishments such as karaoke bars or Chinese restaurants tend to ignore such regulations. While having dinner or lunch, in moments of relaxation, they smoke a packet or more of tobacco. In their stores, Chinese individuals usually go outside to smoke since there are stricter regulations in these places.

In the case of youth and women, cultural integration is more objective:

*"There is no difference in the tobacco and alcohol consumption among students and the new generation, but there is a difference in families between 30–40 years old"* (C-30, man, 41 years).

Awareness campaigns and health education in Spain, as well as the legal regulation of the sale of tobacco in specialized establishments and only to those over 18 years of age, have made access difficult for minors who have not become current smokers. However, smoking is considered not appropriate to women by the Chinese culture:

*"Women do not usually smoke because it is frowned upon"* (C-52, woman, 42 years)*; "The woman smoker is like* . . . *what it's usually said here* . . . *a wh\*\*\*"* (C-43, woman, 36 years).

As it happens with tobacco, alcohol consumption has also a social acceptance within this community.

*"They drink a lot, it is essential in parties and celebrations (...). Chinese entrepreneurs eat at restaurants with other colleagues and order many expensive wines; they want the best to impress and treat business"* (C-10 man, 32 years).

There is a clear trend towards cultural integration when Chinese immigrants combine typical alcoholic beverages from both cultures and countries, such as beer and high-strength Chinese spirits.

*"Beer is becoming more popular and red wine is very common because this is the drink that best combines with Chinese food, but in family gatherings, more Chinese liquors are taken"* (C-131, woman, 27 years).

*"Chinese men drink a liquor called "bai jiu" (...). It's a distilled 60-degree liquor. It is a national drink, like a brandy, which is taken with meals, to reach business agreements,* etc. *It's a drink for Chinese [laughs]. We say "ganb ¯ ei" [cheers] and drink it in one shot" ¯* (C-73 man, 34 years).

#### **4. Discussion**

Our results further advance the understanding of acculturation strategies among Chinese immigrants in Europe, particularly in Spain. According to our theoretical framework (Berry's Model of Acculturation), our findings reveal that "separation" was still the predominant strategy, followed by "integration" and "assimilation", while "marginalization" was not present in this Chinese immigrant population. In other words, most Chinese immigrants maintain a strong link to the customs of their home country, integrating few aspects

of the host culture, which, in other words, favors the process of identity and collective self-esteem among this group.

This predominance of "separation" found in our sample has already been identified in a previous study, which included older Chinese immigrants in the United States. Considering that acculturation may influence eating patterns/diet, exercise, chronic disease, and mental health management, they found a strong identification of their participants with the Chinese culture (identificational acculturation), a high dependence on Chinese behavioral patterns and intraethnic networks, limited intergroup interactions (behavioral acculturation), and a strong maintenance of Chinese cultural values, while incorporating some American cultural learning (cognitive acculturation) [32]. The same patterns of "separation" were also observed in the Spanish context, in which Chinese immigrants tend to live in neighborhoods with a high density of Chinese individuals [33].

For Chinese immigrants, this cultural "separation" may be justified by the fact that, in the Chinese society, Confucianism posits the family as the fundamental unit of society, incorporating economic and social functions. Confucian values can be observed both in intergenerational relationships within the family and other social interpersonal relationships, which allow them to maintain the positive effect of family and community cohesion [34]. Current studies in Spain show that even younger Chinese immigrants of the second generation have a positive and strong sense of belonging towards their ethnic group. Nevertheless, they also believe that respect for the customs and traditions of both countries is important ("integration"), as well as good behaviors to be accepted by the new society [3]. In our case, since we investigated first-generation Chinese immigrants, this integration is less obvious and participants tended to maintain strong ties with their native culture. Nevertheless, it is important to note that younger Chinese immigrants tended to have a more open relationship with the host culture, as identified in the relationship with school friends and physical activity.

Even in older immigrants, the "integration" strategy can take place, as was revealed by the consumption of Western foods and the "forced" relationship with Spanish clients and co-workers. Health managers and health professionals should be aware of this aspect of the Chinese immigration in an attempt to value the Chinese culture, improving the adherence to treatment and interventions and also recognizing possible ways to integrate first-generation Chinese immigrants into the host culture. This integration is important since studies have demonstrated that biculturalism is strongly associated with better psychological and sociocultural adjustment, resulting in better health outcomes [35].

Despite the aforementioned strategies, our findings also revealed that prejudice exists among Spanish persons towards Chinese immigrants. According to Julián, high levels of prejudice on the part of the host population are linked to the preference for the attitude of assimilation, while low levels of prejudice are related to attitudes of integration [22]. According to previous studies in Europe, acquisition of nationality is an indicator of integration. This nationalization is usually motivated by an identity-related choice, but also as a utilitarian decision to deal with the economic crisis [36]. Different from other immigrants, Chinese individuals mostly choose to maintain their nationality, since they work in their own businesses and, for this reason, usually do not suffer unemployment or other economic problems that need nationalization [37]. This evident "separation" is noted by participants who reported avoiding prejudice in the relationship with Spanish individuals by using the tight support of the Chinese community and avoiding informal contact.

Regarding health lifestyles, the acculturation process can be shown in different ways. On the one hand, if "separation" is common among older immigrants, than "integration" is more common among younger individuals. Corroborating our results, a Spanish study on eating habits of the Chinese immigrant population in Catalonia showed that the Chinese immigrants tried to maintain their diet of origin. On the other hand, the preference of the local diet by the children, work schedules, and lack of time were important barriers to keep this behavior [38]. A cross-sectional survey measured obesity risk reduction behavior and degree of acculturation among Chinese Americans. Asian-identified participants were

most likely to follow traditional healthful Chinese food patterns, and Western-identified individuals were more apt to engage in leisure physical activity. Individuals categorized as bicultural were prone to use limited amounts of fats or oils when preparing foods [4]. These results reveal the positive effect on health derived from preserving at least part of the minority ethnic identity. Nevertheless, not all "integration" behaviors are harmful and the incorporation of sports for young immigrants proved to be beneficial to their health [39].

According to other authors, when the behavior is similar to those from the country of origin, it is possible that the behavior will be maintained by the migrant person and will be difficult to modified. For example, this situation can be better observed concerning the use of alcohol and tobacco [40], which was more prevalent in Chinese men in our study. On the other hand, immigrants could incorporate new behaviors to achieve integration, such as the increase in tobacco consumption in Chinese women [41].

Although some studies have concluded that Chinese migrants suffer a double marginalization and live in a constant balance between "out of place" and "in place" [42], marginalization (i.e., not identifying with any culture or having no interest in your own) was not a main issue for our participants.

In any case, ethnic minorities cannot always choose their preferred acculturation strategy, as the success of their acculturation strategy also depends on the larger society's strategies (i.e., multiculturalism, melting pot, segregation, and exclusion) [12] and this should be considered while interpreting our findings.

These results have several clinical implications, revealing that Chinese immigrants still use "separation" as the predominant strategy, maintaining their cultural values and usually not incorporating aspects of the host's culture. On the one hand, this approach helps them keep their values; on the other hand, it allows them to avoid integration with the host's culture, which could in some occasions stigmatize them. Understanding the barriers to "integration" and valuing the native culture is essential to provide a more comprehensive and integrative treatment to these immigrants, improving their quality of life and health outcomes. Since acculturation is very distinct between younger and older individuals, as revealed in our study, intergenerational activities could be an important strategy to help in the "integration" process, since younger individuals tend to have a better relationship with the host community and can help decrease the "separation" and the fear of "assimilation" of their older counterparts.

Limitations and future directions for research are as follows: Owing to the lack of a standard methodology for measuring acculturation, acculturation orientations were used as a theoretical template to analyze ethnic minority' discourses [32,43]. Although future studies could utilize bi/multidimensional scales and take into account the dynamic/transitory aspect of the acculturation process when studying health behaviors and still find discordant findings [31,44], the authors assume that the dynamic nature of the acculturation process can be lost when this theory is translated into a measurement instrument. In addition, new research should deepen investigations into the mixed vision of both an ethnic minority and an ethnic majority, since it allows for a better understating of acculturation outcomes [45]. Finally, this study was carried out before the COVID-19 pandemic. For this reason, different factors (e.g., migrants' residency status, mobility, access to information, and healthcare) could have been modified int the immigrant population. Therefore, it is probable that health behaviors could have changed as well, modifying the patterns of acculturation previously studied [46,47].

#### **5. Conclusions**

The present study included the Chinese Migration Process using the Berry's Model of Acculturation. The Chinese immigrant population shows a clear "cultural loyalty", since the immigrants generally remain united with his/her compatriots, have little contact with the native population, and are interested in preserving the distinctive features of his culture of origin, resulting in the "separation" strategy. Although younger immigrants prefer to

maintain their cultural heritage, they also seek contact with Spanish culture through the "integration" strategy.

According to our results, the most beneficial strategies for health are those where customs are maintained from the homeland, so "separation" and then "integration" are the most beneficial. Chinese cohesion offers social and economic support and protects them from perceived external threats. On the contrary, the strategy for assimilating Western Spanish customs can be a risk for their health status, highlighting the increased consumption of tobacco in Chinese women or the approach to a fatty nutritional pattern that could favor cardiovascular diseases. In this context, younger individuals seem to be more exposed to the "integration" strategy and could be important figures to reduce this "separation".

Understanding of acculturation concept and its influence on health behaviors is helpful in identifying risk factors that underlie increased prevalence of chronic diseases and in designing intervention programs to reduce the burden of such diseases and to increase the quality of life in such populations. In addition, health interventions should be designed taking into account the dynamic nature of these acculturative responses and the differences that exist within the same ethnic group.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph18147639/s1, Table S1: Framework of contextual factors influencing acculturation; Table S2: Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

**Author Contributions:** Conceptualization, B.B.; Methodology, B.B. and S.B.-T.; Software, B.B. and G.L.; Formal analysis, B.B., R.d.D.-C., and S.B.-T.; Resources, M.G.-C.-C., L.T.-C., J.V.-E., and A.B.-R.; Data curation, B.B. and R.d.D.-C.; Writing—original draft preparation, B.B., R.d.D.-C., and S.B.-T.; Writing—review and editing M.G.-C.-C., L.T.-C., J.V.-E., D.d.-P.-J., and M.Á.G.-C.M.; Supervision, B.B. and S.B.-T. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by Andalusian Research Ethics Committee, Spain (Code: 0873-N-16).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.

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