**1. Introduction**

According to the Migration Data Portal, the number of international migrants in 2019 reached 271.6 million worldwide as compared to 258 million in 2017. In the European Union, Spain ranked fourth (7%) in the reception of immigrants [1]. The immigration process can be associated with two different conditions. The first one is based on the forced immigration (i.e., asylum seekers or refugees), which may result in mental health problems and infectious diseases to immigrants [2]. The second one is the non-forced immigration (i.e., those living and working in the host country), which tends to promote better life conditions, resulting in challenges towards the degree of integration into the host communities and other social aspects such as work activity or territorial concentration. The latter is considered the case of the Chinese immigrant community in Spain [3,4].

In fact, the entry of Spain into the European Economic Community in 1986 made this country a good destination for the expansion of businesses by the Chinese population [5]. Spain has now occupied the fourth place in the European ranking in terms of immigrants from China [6]. From 2005 to the present date, Chinese individuals represent the most

**Citation:** Badanta, B.; Vega-Escaño, J.; Barrientos-Trigo, S.; Tarriño-Concejero, L.; Muñoz, M.Á.G.-C.; González-Cano-Caballero, M.; Barbero-Radío, A.; de-Pedro-Jimenez, D.; Lucchetti, G.; de Diego-Cordero, R. Acculturation, Health Behaviors, and Social Relations among Chinese Immigrants Living in Spain. *Int. J. Environ. Res. Public Health* **2021**, *18*, 7639. https:// doi.org/10.3390/ijerph18147639

Academic Editors: Lillian Mwanri, Hailay Gesesew, Nelsensius Klau Fauk and William Mude

Received: 23 May 2021 Accepted: 16 July 2021 Published: 18 July 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

common immigrants from Asia [7], constituting the fifth largest nationality of immigrants in Spain (4.46%) [8].

Since their arrival in Spain, this population has established several Chinese restaurants, which promoted the migration of this population to the most important cities of the country and the coastal area. In an attempt to guarantee a strategic location, minimize the competition, and search for new market opportunities, first-generation Chinese immigrants began the so-called "first inward expansion" in the 1990s. Therefore, they migrated to other large cities, which explains the presence of Chinese population in Madrid, Catalonia, and the Canary Islands in the 1980s, followed by the Valencian Community and Andalusia five years later [9,10].

In 2019, the Chinese population living in Andalusia constituted 9% of the total Chinese immigrants in Spain, being the third largest foreign nationality (22,280 inhabitants), behind Moroccan (145,076 inhabitants) and Romanian (79,264 inhabitants) immigrants. Likewise, although Spain is experiencing a decline in the immigrant population of other nationalities due to the economic crisis that Spain suffered since 2008 [6], the Chinese presence in Spain has maintained a steady growth.

According to the "Melting Pot" adaptive theory [11], upon arrival in the host country, immigrants gradually take on cultural aspects and build a new "cultural form", which may have an important influence on their individual, social, and contextual factors. Immigrants usually change the way they dress, what they eat, their greeting habits, and even their values by reducing (i.e., suppressing, forgetting) their way of living. The pace and extent of individual change is related to the degree of cultural maintenance in one's own group, which in turn is linked to the relative demographic, economic, and political situation of the host community [12].

This difficult process called acculturation is influenced by the culture of origin (i.e., religion, language, education), the policies of the hosting country's government [13], age, socioeconomic status, and even by offspring [14]. Although it involves at least two groups, with consequences for both, there is a greater impact for the nondominant group [12].

Social relationships, including the use of language, as well as the acquisition of certain lifestyles, have been used to measure acculturation in Asiatic populations [15], and considering the role of acculturation on immigrant social relations [15] and health behaviors [16,17] is capital for the healthcare of the immigrant population.

Acculturation has been extensively addressed by previous studies. In an Australian study, male immigrants from North Africa/Middle East and Oceania regions were susceptible to weight gain, with higher levels of acculturation being negatively associated with being overweight [18]. In another study, Schotte et al. investigated the association of cultural identity with several indicators of academic achievement and psychological adaptation among immigrant adolescents in Germany, showing that the identification with both the mainstream context and the ethnic context were important factors related to a positive development and adaptation of immigrant adolescents [19].

Concerning the Asiatic immigrant population, the relationship between the acculturation effect and the health lifestyles has been already investigated in the U.S.A, showing that the health risks to this group of immigrants increased due to the North American lifestyle, which, in other words, reflects the negative effect of acculturation. Nevertheless, the mechanisms underlying this relationship are still understudied [20]. In a study with Chinese international students in the Midwest of the U.S.A, the authors found that the stress due to acculturation is a risk factor for substance use. However, on the other hand, bicultural affiliation reduces the likelihood of smoking, drinking, and getting drunk [21].

Despite the previous evidence, there are few studies that address the phenomenon of acculturation related to health. In a recent systematic review, acculturation was associated with mental health aspects such as anxiety, disruptive behaviors, psychological adaptation, satisfaction with life, and emotional exhaustion [22]. Nevertheless, other health variables are seldom investigated in this field of research.

In this context, a recent European concern is the high number of Asian immigrants settled in Spain, particularly Chinese immigrants [23]. However, there are still few studies that have assessed how the migration phenomenon itself may affect the health of these individuals and, to our knowledge, this is the first study that addresses this aspect among first-generation Chinese immigrants in Spain.

This study provides further knowledge on the acculturation strategies that are beneficial or detrimental to the health of immigrants. This will allow health managers and healthcare professionals to design and promote healthcare interventions and to prevent unhealthy lifestyle behaviors among immigrants. In addition, healthcare services should be configured taking into account the essential cultural variables of the Chinese immigrants, since these variables could be determinants for the success or failure of healthcare in this population.

#### *Theoretical Framework*

Several theories have studied the immigrant integration into host societies using theories and concepts such as immigrant acculturation and adaptation [24]. This study considers acculturation as "a process of group and individual changes in culture and behavior that result from intercultural contact" [25].

The acculturation model used by this study was first proposed by Berry [24] and is considered a bidimensional model, which is based on the fact that the acculturation entails two independent dimensions: maintenance of the culture of origin and adherence to the dominant or host culture. This theoretical perspective proposes that immigrants can adopt up to four possible adaptation strategies: (a) assimilation, when the immigrant abandons his identity of origin and acquires that of the majority group; (b) integration or biculturalism, when there is a strong identification with both societies or cultures, so that the immigrant preserves the characteristics of their culture, but also participates or shares the culture of the majority group; (c) separation, when the immigrant does not try to establish relationships with the majority group and seeks to reinforce their ethnic identity and; (d) marginalization, in which the immigrant loses his native cultural identity, and also does not want or does not have the right to participate in the culture of the dominant group [12,26]. These aforementioned strategies are based on the idea that immigrant groups and their individual members have the freedom to choose how they want to engage in intercultural relations [12].

Therefore, this study aims to identify unique acculturation experiences and describe their influences on social relations and health behaviors among first-generation Chinese immigrants (foreign-born population who emigrated to Spain when they were children, adolescents, or adults) in the South of Spain, including food patterns, physical exercise, and tobacco and alcohol use.

#### **2. Materials and Methods**

#### *2.1. Design*

A qualitative, exploratory, and descriptive design using a phenomenological approach [27] was conducted in the southern region of Spain. This design allowed us to explore a particular topic of interest in a specific context, and to perform an analysis focusing on subcultural groups rather than involving entire societies.

In the present study, we opted to use the Berry's Model of Acculturation as described above [26]. Despite several theories and models of acculturation used for research, bidimensional approaches such as Berry's model may better conceptualize acculturation and explain in more detail the health habits as compared to other unidimensional approaches [28].

Data collection consisted of semi-structured interviews with Chinese immigrants, informal conversations, and field notes, and all were carried out by the main researcher (B.B) over six months in 2016/2017.

#### *2.2. Data Collection*

Our study took place in Andalusia, the southernmost region of Spain and Europe. The focus was on participants' shared behaviors and experiences; thus, we worked under the assumption that they share cultural perspectives, even if they do not know each other. Participants were recruited through Chinese businesses (e.g., bazaars, restaurants, grocery stores, fashion stores, technology stores, and wholesale businesses) and community institutions (e.g., educational institutions, Asian cultural centers, and health services). In order to increase the number of participants, a "snowball sampling" procedure was also used. This is a valid method to conduct face-to-face interviews while investigating an ethnic minority population [29]. Participants were included in the study if they were adult immigrants of Chinese origin, emigrated to Spain, and were able to communicate in Mandarin Chinese, Spanish, or English.

Semi-structured interviews were carried out face-to-face and lasted between 30 to 60 min. Statements of informed consent for all participants were obtained. The goal of the semi-structured interviews was to create the framework for the participants in which they were comfortable to talk about sensitive issues, while also giving the researcher the opportunity to ask for elaborations about specific topics, explanations of observed events, and clarification of ambiguities. All the interviews were audiotaped and transcribed verbatim by the main researcher (B.B) and data collection continued until criteria saturation.

Information from field notes and informal conversations were also included concerning witnessed events, verbatim verbal exchanges, and the researcher's personal interpretations of events. Informal conversations and the interviews allowed the researcher to examine whether interpretations of meanings behind observed behavior coincided with participants' own understandings. All interviews were conducted using the following starting open questions: "What were the reasons for the migration? What has been your experience during migration and upon arrival in the host country? And over the years? What kind of relationships do you have with the Spanish population and your ethnic group? Since you are in Spain, what eating habits do you have? And what about physical activity? Have you started or changed alcohol or tobacco use?" All the questions were agreed upon and discussed among the authors, taking into account the theoretical aspects that explain acculturation and acculturative strategies (Table 1). A consensus among researchers was reached on these open questions. After this first stage and before interviewing the participants, two native Chinese professors who speak Spanish provided feedback on the interview script. Grammatical errors were detected and corrected, and this version was considered appropriate and understandable for the Chinese population. When the first two interviews were transcribed, they also verified the adequacy of the answers to the questions, determining the reliability of the script.

### *2.3. Data Analysis*

The qualitative analysis was carried out following the steps proposed by Braun et al. [30]: (1) familiarization with the data; (2) generation of categories; (3–5) search, review, and definition of themes; and (6) the final report. The data obtained were captured through audio recording and with the use of a field diary. Since some statements were recorded in Chinese, the following translation process was carried out: a Chinese-English translation by a Chinese native (*n* = 2) and an English-Chinese back-translation by a translation company.

Transcription, literal reading, and theoretical categorization were performed, and the NUDIST Nvivo (version 12) software (QSR internacional, Melbourne, Australia) was used. Data analysis started with individual readings in order to get an overview of respondents' experiences. Two researchers read all field notes and interview transcriptions several times, to gain an overall understanding of the content. The other authors read samples of the field notes and interviews to obtain understanding. The analysis continued by organizing descriptive labels, focusing on emerging or persistent concepts and similarities/differences in participants' behaviors and statements. The coded data from each participant were

examined and compared with the data from all the other participants in order to develop categories of meanings.


**Table 1.** Development of the interview script.

When a basically clear pattern emerged with respect to the ideal types of acculturation strategies [26], it was used to critically reflect the data and theoretically frame the results. Furthermore, numerous contextual factors influence the trajectory of their adaptation to a new society. To overcome this limitation, social patterns and contextual factors were carefully considered in the measurement process [31] (see Supplementary Materials— Table S1). Two main themes *("Social Relations"* and *"Health Lifestyles"*) reflected all of the assessed domains. A final report was prepared with the statements of the Chinese immigrants displayed in the following format: "C-questionnaire number, sex, age".

This research followed the criteria of The Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Supplementary Materials—Table S2). The methods used in order to guarantee quality were data triangulation, including participants with different sociodemographic characteristics, and triangulation of data analysis via different researchers.
