International Journal of

Environmental Research
and Public Health

Study Protocol
Mixed Methods Study Protocol: Language Identity, Discrimination,
and Mental Health among Multilingual 1.5 Generation
Asian/Asian American Immigrant Young Adults
Chulwoo Park 1, * , Mark Edberg 2 , Janet Yougi Bang 3 and Avizia Yim Long 4

1 Department of Public Health and Recreation, San José State University, San Jose, CA 95192, USA
2 Department of Prevention and Community Health, Milken Institute School of Public Health, George
Washington University, Washington, DC 20052, USA; [email protected]
3 Department of Child and Adolescent Development, San José State University, San Jose, CA 95192, USA;
[email protected]
4 Department of World Languages and Literatures, San José State University, San Jose, CA 95192, USA;
[email protected]
* Correspondence: [email protected]

Abstract: Language identity, an understudied factor, can influence isolation and discrimination,
leading to disparities in well-being and mental health among immigrants. This study aims to
investigate the role of language identity on structural racism and discrimination among 1.5 generation
Asian/Asian American immigrants in a diverse U.S. state. We developed a three-step sequential
approach: Stage 1—qualitative analysis (1A, focus group discussion; 1B, in-depth interviews); Stage
2—quantitative analysis (2A, language identity measurement scale; 2B, cross-sectional online survey;
2C, multivariate multiple linear regression); Stage 3—another round of qualitative analysis (3A,
follow-up in-depth chronological interviews). Therefore, this study will contribute to the field by
introducing a novel three-step mixed methods approach, marking a notable improvement over
conventional explanatory or exploratory sequential designs.

Citation: Park, C.; Edberg, M.; Bang,

Keywords: 1.5 generation; language proficiency; language identity; mental health; mixed methods
J.Y.; Long, A.Y. Mixed Methods Study
study; health disparity
Protocol: Language Identity,
Discrimination, and Mental Health
among Multilingual 1.5 Generation
Asian/Asian American Immigrant
Young Adults. Int. J. Environ. Res. 1. Background
Public Health 2024, 21, 1311. https:// There has been increasing attention to multilingualism as an important issue for immi-
doi.org/10.3390/ijerph21101311 gration and globalization. Relative to the many home countries for Asian/Asian Americans,
Academic Editor: Diego the U.S. is a highly pluralistic society that embraces various classes, religions, languages,
Gomez-Baya gender, regions, urban/rural areas, and other identities [1]. American culture has a power-
ful attractive force for immigrants [2]. Individuals in culturally pluralistic societies tend to
Received: 5 August 2024 have attitudes that favor connection with other individuals and groups. Although ethnic
Revised: 29 September 2024
and racial groups in a pluralistic society may remain separate from different cultures and
Accepted: 29 September 2024
groups, they can interact to create a new common culture and a unique society, typically
Published: 30 September 2024
referred to as the ‘melting pot’ [3–5].
Asian/Asian American immigrant young adults who came to the U.S. with their
families at an early age, called ‘1.5 generation’, are one of the neglected and unsupported
Copyright: © 2024 by the authors.
immigrant groups that have not been extensively researched. These young adults face
Licensee MDPI, Basel, Switzerland. unique issues with respect to identity and language. Multilingual language learning can
This article is an open access article occur at any life stage [6–8] among immigrant populations in the U.S. Being exposed to
distributed under the terms and English as an additional language (L2) after their first language (L1) is a common pattern,
conditions of the Creative Commons and it is important to consider how language is related to complex identities in multilingual
Attribution (CC BY) license (https:// individuals [9], and specifically may shape a sense of language identity, a construct we
creativecommons.org/licenses/by/ explore in the present work. For many Asian/Asian American immigrants, as soon as the
4.0/). 1.5 generation arrives in the U.S., they are exposed to a new dominant language and new

Int. J. Environ. Res. Public Health 2024, 21, 1311. https://doi.org/10.3390/ijerph21101311 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2024, 21, 1311 2 of 19

culture, and familiarity with this new environment is essential for them to feel accepted
into U.S. society.
Although language identity is not well understood, acculturation has been a common
related area of study. Acculturation involves changes in identification, social skills, attitudes,
and values that immigrants experience while adapting to the host culture and is also linked
to mental health issues—psychological distress, depression, and anxiety [10–14]. While
some immigrants willingly adjust to the dominant culture, others might still be attached
to their culture of origin, the minority culture, and feel that adjusting to the other culture
is challenging [15]. Norton (2010) highlights that language learners’ identities are shaped
by their access to social and educational resources and interactions with dominant and
marginalized linguistic groups [16]. This work also introduces the concept of investment,
which contrasts with traditional motivation by focusing on how learners invest in language
learning to enhance their social identity [16]. This theory is related to poststructuralist views,
suggesting that identity is fluid and negotiated through power dynamics, with language
acquisition success depending not just on ability but also aligning with sociocultural or
ethnic factors [17].
In recent decades, societal advancements and theories illustrate the numerous complex-
ities to consider for how identities are shaped for 1.5 generation Asian/Asian Americans.
Social media use among recent migrants in the era of globalization, such as exchange
students or foreign students, to interact with host country nationals was predicted to lead
to poorer adaptation to the host country [18]. Their attempts to connect with host nationals
through social media could lead to feelings of disconnect, reduced perceived support, and
misunderstandings due to language barriers, ultimately hindering their well-being and
psychological adaptation [19–22]. In contemporary societies, migration, transnationalism,
and intersectionality have been pivotal to human settlement [23]. For example, Kimberlé
Crenshaw’s reconceptualization of race through intersectionality illustrated how multiple
dimensions intersect for women of color who experience violence, racism, and sexism. This
work exemplified how multiple social identities intersect and influence individuals’ expe-
riences of oppression or privilege for marginalized communities [24]. For 1.5 generation
Asian/Asian Americans, the intersection of multiple dimensions can be seen through how
language interacts with other facets of identity, such as race, gender, class, ethnicity, and
immigration status. Additionally, transnationalism, defined by immigrants’ new social en-
tanglement leaving behind their former life [25], could help explore how language identity
is formed through cross-border interactions and multiculturalism.
In addition, during the COVID-19 pandemic, there was a significant increase in
instances of anti-Asian violence, xenophobia, and bias against Asian/Asian American
immigrants in the U.S. [26–29]. Asian Americans are often treated as foreigners by others in
the dominant society, regardless of their citizenship status or how long they have lived in the
U.S., a phenomenon known as the perpetual foreigner stereotype [30]. This often appears
in subtle forms, such as microaggressions, including compliments on an individual’s
proficiency in English or inquiries about their nationality or place of origin [31,32]. A 2023
survey by the Pew Research Center stated that one-third of Asian Americans have been told
to ‘go back to their home country’, a sentiment that surged alongside the rise in anti-Asian
hate crimes during the COVID-19 pandemic [33]. According to the Center for the Study
of Hate & Extremism, anti-Asian hate crimes in select U.S. cities reached a record high of
369 incidents in 2021; 121 of those cases (33%) were reported in California [34]. Among
selected U.S. cities, San Francisco and San Jose in California showed a notably high increase
of hate crimes from 2020 to 2022, or 567% and 89%, respectively [34]. Still, hate crime
incidents have been significantly under-reported due to challenges with understanding
systems of reporting and cultural norms that uphold feelings to ‘keep quiet’ [35–37].
The mental health of Asian/Asian American immigrant young adults is impacted
by pressure to meet high parental academic expectations, the challenges of balancing two
cultures, family obligations, and experiences of discrimination or isolation [38]. Asian
Int. J. Environ. Res. Public Health 2024, 21, 1311 3 of 19

cultural norms stigmatize the importance of seeking mental health care, which leads to
mental health programs being considered unimportant [39].

1.1. A Gap in Knowledge

Challenges with perceived language proficiency are associated with several men-
tal health issues—psychotic, mood, anxiety, and post-traumatic stress disorders—in mi-
grants [40]. Language acquisition research suggests that there are numerous ways in which
language skills in one language may support the learning of another language [41–45].
Current research on bilingual and multilingual language development [7–9,46–48] within
diverse sociocultural contexts [49–53] has focused on the linguistic aspects of language
acquisition or positioned language as an integral part of culture. Studies have focused on
the relationship between language proficiency and various forms of identity, including
generic [54,55], cultural [56,57], social [58], or ethnic [59] identity across different genera-
tions of immigrants. What remains unknown, however, is how 1.5 generation individuals
would begin to acculturate when they are mainly exposed to an L2 and establish a sense of
language identity in their new community with a new dominant language. Additionally,
less attention has been given to how individuals perceive the impact of language identity
in various settings where one or more languages are used in interactions, and how this is
connected to their well-being and mental health. This gap has led to a lack of understanding
of the connection between the language identity and mental health of the 1.5 generation.
Language identity has been discussed in sociolinguistic literature as one’s connection
to their sense of self through the socio-cultural contexts in which they use language to
engage with others [16]. The methods proposed in this article are uniquely designed to
capture the role of language identity and its consequences across the multiple sociocul-
tural contexts that 1.5 generation immigrants may face. While proficiency in a language
and a sense of language identity might be related to experiencing rejection, prejudice, or
discrimination within different segments of cultural and ethnic communities, there are
several aspects of separation and marginalization that may be uniquely tied to language
identity for 1.5 generation immigrant young adults. We hypothesize that these experiences
could impose significant psychological costs and stimulate social conflict in both their own
communities and the dominant society. Moreover, the construct of language identity may
play a distinct role in individuals’ psychological well-being and mental health, as it can
illuminate how language influences self-expression, cultural belonging, and social interac-
tions. A strong connection to one’s own sense of language identity can foster resilience and
coping strategies, helping individuals overcome the challenges of ethnocultural identity
confusion, acculturative stress, and racism and discrimination. Ultimately, this understand-
ing can inform tailored mental health interventions that resonate with their unique cultural
experiences and enhance their overall well-being as shaped by their language identity.

1.2. Methodological Aim

Using a multiple mixed methods design, we will investigate how perceived language
proficiency and language identity among 1.5 generation Asian/Asian American immigrant
young adults are associated with mental health disparities. The primary methodological
aim of this three-step sequential mixed methods study is to integrate qualitative depth and
quantitative breadth to comprehensively explore the relationships between language identity,
acculturative stress, and mental health outcomes among 1.5 generation Asian/Asian American
immigrants in the United States. The proposed procedure focuses on a purposive sample of
our surrounding community in one state with diverse Asian/Asian American populations.
We will also examine how language identity impacts various mental health outcomes through
various mediators—such as ethnic identity, acculturative stress, racism, and discrimination.
Additionally, experiences of anti-Asian hate crimes, which could be inextricably tied to the
perceptions of their language identity, will be explored as a moderator.
 Asian/Asian American populations. We will also examine how language identity impacts
various mental health outcomes through various mediators—such as ethnic identity, ac-
culturative stress, racism, and discrimination. Additionally, experiences of anti-Asian hate
crimes, which could be inextricably tied to the perceptions of their language identity, will
Int. J. Environ. Res. Public Health 2024, be explored as a moderator.
21, 1311 4 of 19

2. Methods and Design

2.2.1. Study Protocol
Methods and Design
2.1. Study Protocol
The proposed mixed methods study uses a three-step sequential mixed methods ap-
proach,The comprising
proposed mixed qualitative
methodsanalysis
study (Stage
uses1)a and quantitative
three-step analysis
sequential (Stage
mixed 2), fol-
methods
lowed by qualitative
approach, comprisinganalysis (Stage
qualitative 3), over(Stage
analysis the four-year research period
1) and quantitative (Figure
analysis 1). The
(Stage 2),
study protocol
followed begins with
by qualitative focus(Stage
analysis group3),discussions (Stage 1A)
over the four-year to understand
research the back-
period (Figure 1).
ground
The studyofprotocol
language identity,
begins withfollowed
focus groupby in-depth
discussions interviews
(Stage 1A) (Stage 1B) to explore
to understand per-
the back-
sonal experiences
ground of languagewith language
identity, identity.
followed Subsequently,
by in-depth interviewsinsights
(Stage 1B) from focus group
to explore personaldis-
experiences
cussions and with language
in-depth identity. will
interviews Subsequently,
inform theinsights from focus
development of agroup discussions
language identity
and in-depth interviews
measurement scale (Stage will inform
2A). the development
A cross-sectional onlineofsurvey
a language
will beidentity measurement
administered (Stage
scale
2B), (Stage
which 2A).
will Abecross-sectional
analyzed using online survey will multiple
a multivariate be administered (Stage 2B), (Stage
linear regression which will 2C).
be
Thisanalyzed using analysis
quantitative a multivariate multiple
will assess how linear
our regression (Stage 2C).
newly developed This quantitative
measure of language
analysis
identity,will
alongassess
withhow our newly
existing developed
measures measure
of perceived of language
language identity,
proficiency, along
would with
relate to
existing measures of perceived language proficiency, would relate
our primary outcomes through the mediator effects of ethnocultural identity confusion, to our primary outcomes
through the mediator
acculturative stress, and effects of ethnocultural
racism identityWe
and discrimination. confusion,
will alsoacculturative stress, and
explore a moderator of
racism and discrimination.
anti-Asian We will also
hate crime victimization explore
between a moderator
language of anti-Asian
identity and our proposedhate crime vic-
media-
timization between
tors. The final steplanguage
involves identity and our
a qualitative proposed
analysis mediators.
to capture The final
additional step involves
detailed aspects
afrom
qualitative analysis to capture additional detailed aspects from the
the participants, providing an in-depth understanding of how perceived language participants, providing
an in-depth
skills understanding
and language identityof inform
how perceived
the sense language skills
of overall and language
identity identitythrough
and well-being inform
the sense of overall identity and well-being through in-depth interviews
in-depth interviews (Stage 3A). We will utilize both statistical and qualitative analysis soft- (Stage 3A). We
will utilize both statistical and
ware for this mixed methods project. qualitative analysis software for this mixed methods project.

Figure1.1.Study
Figure Studytimeline
timeline(Stages
(Stages1–3).
1–3).

2.2. Target Participants

The definition of the 1.5 generation is supported by extensive literature describing
individuals who describe different experiences than individuals who are considered first or
second generation [60]. Individuals who are 1.5 generation are connected to cultures where
‘their heritage culture is stronger than or similar to the second-generation immigrants,
but not quite to the level of first-generation immigrants either’ [61]. This group typically
Int. J. Environ. Res. Public Health 2024, 21, 1311 5 of 19

includes individuals who were born in their home country but migrated to new countries in
elementary, intermediate, or high school [62,63]. We specified 1.5 generation Asian/Asian
American immigrant young adults, our target participants in this study, as those who
migrated to the U.S. with their parents (1st generation) from Asian countries when they
were children or adolescents aged between 5 and 17 years, have been living in the U.S. for
at least 12 months, and whose current ages are between 18 and 29 years. Our study will be
conducted in California, home to 11 million immigrants (25% of the foreign-born population
nationwide) with varied levels of educational attainment [64], most of whom speak at least
two languages [65]. Nearly half (48.3%) of California children are living with foreign-born
parents [66]. Further, more than half of recent arrivals in California (53%) between 2010 and
2019 were from Asian countries [65]. Foreign-born residents represent more than one-third
of the population in 5 California counties, and 4 of them—Alameda, San Mateo, Santa
Clara, and San Francisco—are located in the San Francisco Bay Area [65], where 23.3% of
the population is Asian (1,664,384 out of 7,150,739) [67]. The Asian community in the Bay
Area is one of the fastest-growing groups representing diverse ancestry backgrounds and
cultures [68]. Thus, we will focus our study and recruitment efforts in the Bay Area, which
is the main site for this research study.

3. Stage 1: Qualitative Analysis

We will conduct a qualitative study to capture the meaning of language identity for
Asian/Asian Americans and subsequently develop a new language identity measurement
scale. In the process of developing this scale, we will delineate various socio-cultural
contexts based on the country of origin that significantly contribute to an individual’s
linguistic identity for 1.5 generation Asian/Asian Americans. These socio-cultural contexts
encompass the home environment, educational or work settings, interactions with peers,
family dynamics, and the influence of one’s occupation or professional life, as well as
religious institutions. By identifying and understanding these socio-cultural contexts,
we can gain valuable insights into the multifaceted nature of language identity for this
population. Assessing the significance of each context allows for a nuanced exploration
of how individuals prioritize and connect with different aspects of their linguistic and
social environment. This exploration extends to understanding the broader sociolinguistic
landscape, including the role of the home language versus English and the nuanced ways
in which individuals navigate linguistic choices in different contexts.
As part of the measurement scale development, we will investigate which specific
socio-cultural context holds the highest importance for individuals, which allows for a
focused understanding of the dominant factors shaping language identity. Additionally,
evaluating the balance or preference between the use of a home language (L1) and an
additional language, English (L2), provides a quantitative dimension to the scale. Finally,
the measurement scale should capture the depth of connection between social-cultural
context and language identity. This involves assessing the extent to which an individual’s
language identity is intertwined with various socio-cultural contexts. By incorporating
these dimensions into the scale, we can create a comprehensive tool that not only measures
language identity but also provides a rich understanding of the intricate interplay between
language and socio-cultural environments. We will conduct focus group discussions
(Stage 1A) to understand the background of participants’ language identity, then move on
to in-depth interviews (Stage 1B) to capture detailed information that was not found from
focus group discussions.

3.1. Stage 1A: Focus Group Discussions

3.1.1. Study Design
Hybrid semi-structured focus group discussions will be conducted both in-person and
virtually using English at a university located in the San Francisco Bay Area. Although we
will use English as a common shared language, participants will be encouraged to share
and explain words or phrases as desired in any additional languages. The space will be
 3.1. Stage 1A: Focus Group Discussions
3.1.1. Study Design
Hybrid semi-structured focus group discussions will be conducted both in-person
and virtually
Int. J. Environ. Res. Public Health 2024, 21, 1311 using English at a university located in the San Francisco Bay Area. Although
6 of 19
we will use English as a common shared language, participants will be encouraged to
share and explain words or phrases as desired in any additional languages. The space will
be created to make participants comfortable sharing their home languages, words,
created to make participants comfortable sharing their home languages, words, phrases,
phrases, and ideas. The average duration of each focus group discussion will be approxi-
and ideas. The average duration of each focus group discussion will be approximately 90 to
mately
120 min90totoprovide
120 min to provide
sufficient sufficient
time time forto
for participants participants to each
interact with interact with
other. eachthe
From other.
peer
From the peer group dynamics, participants will be encouraged to share their
group dynamics, participants will be encouraged to share their thoughts to understand thoughts to
understand how they use language in different sociocultural
how they use language in different sociocultural contexts. contexts.

3.1.2.
3.1.2. Recruitment
Recruitment
We
We will
will use
useaapurposive
purposivesampling
samplingstrategy
strategyto toidentify
identifyandandrecruit
recruittarget
targetparticipants.
participants.
The
The inclusion
inclusion criteria
criteria of
of the
the participants
participants for
for this
this study
study are: (1) (1) Asian
Asian or or Asian
Asian American
American
young
young adults,
adults,(2) (2)they
theywere
werechildren
children oror
adolescents
adolescents agedaged5–17 years
5–17 when
years whencoming to the
coming to
U.S., (3) they
the U.S., (3) came
they with
cametheir
withparents (1st generation),
their parents (4) they have
(1st generation), livedhave
(4) they in the U.S. in
lived forthe
at
least
U.S. 12formonths,
at least 12(5) months,
their current agescurrent
(5) their are 18–29 years,
ages and (6)years,
are 18–29 they currently
and (6) they livecurrently
in Santa
Clara
live inCounty. The term
Santa Clara 1.5 generation
County. The term implies that the implies
1.5 generation individual thatgrew up in a country
the individual grew
outside
up in a the U.S., and
country thusthe
outside wasU.S.,
exposed to one
and thus or more
was exposed languages
to one or that differ
more from Ameri-
languages that
differ
can from American
English. English. that
This also suggests Thisthey
also are
suggests
able tothat they are able
understand and/orto understand
communicate and/or
(e.g.,
communicate
gestures) (e.g., gestures) inthat
in a language/culture a language/culture
differs from American that differs
English from American
norms. We willEnglish
send
norms.invitations
email We will send email invitations
to university to university
or college-wide offices or college-wide
and buildings offices
(e.g., and buildings
international
(e.g., international
student student offices,
offices, undocumented undocumented
student studentfinancial
service centers, service centers,
aid andfinancial
scholarshipaid and
of-
scholarship offices, and dormitories) and various student clubs or organizations
fices, and dormitories) and various student clubs or organizations for young adults (e.g., for young
adults (e.g.,
academic andacademic
honoraryand honorary organizations,
organizations, cultural and
cultural and religious religious organizations,
organizations, special inter-
special
est interest organizations,
organizations, and non-profit andorganizations)
non-profit organizations)
located in Santalocated in Santa
Clara County Clara County
(Figure 2),
(Figure
and post2),theand post theon
invitations invitations
their socialonmedia
their and
social media and
university university
mobile app. A mobile
purposive app.and A
purposivesampling
snowball and snowball sampling
strategy will bestrategy
employed,will recruiting
be employed, recruitingwho
participants participants who
express their
express their
willingness towillingness
participate in to participate
a focus group in adiscussion.
focus group discussion.will
Participants Participants
be contacted willviabe
contacted via email and invited to advertise and disseminate qualitative
email and invited to advertise and disseminate qualitative study information to potential study information
to potential
other other participants
participants through social through
mediasocial media (e.g.,X,
(e.g., Instagram, Instagram, X, and LinkedIn).
and LinkedIn).

Figure
Figure 2.
2. Distribution
Distributionof
oftarget
target educational
educational institutions
institutions and
and organizations.
organizations.

3.1.3. Data Collection

A total of approximately 40 participants will be recruited to join focus group discus-
sions. Each focus group discussion will seat up to 8 participants, for a total of 5 focus
groups. As an incentive, a $40 gift card will be provided to all participants. The discussions
will be conducted using a moderator’s guide addressing key initial questions, such as ‘How
does speaking more than one language contribute to your sense of racial/ethnic identity?’,
‘Do you believe that English is “replacing” your home language(s) in any way? If so, how
Int. J. Environ. Res. Public Health 2024, 21, 1311 7 of 19

does this make you feel in relation to your sense of identity?’, and ‘Do the languages you
use affect your sense of belonging as an immigrant? If so, why?’. Each of the focus group
discussions will be audio-recorded and transcribed verbatim. To gain initial transcriptions,
Otter.ai Business (Otter, Los Altos, CA, USA), a speech-to-text transcription software, will
be used. Undergraduate research assistants will review those initial transcriptions to final-
ize verbatim transcriptions. Transcript preparation will also include redacting identifying
information. The recordings will be viewed only by the research team and not shared.

3.1.4. Data Analysis Process

Following transcription preparation, we will use qualitative analysis software, NVivo
(QSR International, Pty, Ltd., Doncaster, Australia), to analyze five verbatim transcripts.
Such software will facilitate the organization and coding of main codes and subcodes, with
relevant quotes linked to each of those codes. Qualitative analysis will proceed in two
methods: deductive and inductive approaches [69]. First, we will use deductive coding
from the predefined topics outlined in the focus group guide, which will help ensure
that key areas of predetermined interest are systematically addressed. Table 1 presents
the anticipated deductive codes and their subcodes. Next, we will conduct an inductive
coding process to capture newly discovered themes and insights that emerge from the data,
which will be integrated wherever appropriate. Two members of the research team will
independently identify codes from the first two transcripts, followed by a cross-checking
process to reach a consensus on the preliminary coding frame. This collaborative approach
will enhance the reliability of our coding. After completing this initial phase of the inductive
coding process, we will examine response patterns within and across codes to identify
overarching themes. As we analyze the remaining transcripts, we will iteratively refine the
coding frame through ongoing inductive process, allowing for the integration of emerging
insights. The final coding tree will consist of themes, categories, and codes, providing a
comprehensive framework for understanding the qualitative data. Regarding the selection
of key quotes that represent each of the main codes and subcodes for reporting, we will
identify them across all five focus groups to ensure that opinions and thoughts from each
group are equally represented.

Table 1. Stage 1A: Deductive approach for focus group discussions.

Main Code Subcode

preliminary context of using one language compared to
Background the other language, relative connection between
language usage and language identity
perceived language proficiency and its overall
Language proficiency
relationship with participants’ background in the group
Language identity language identity separated from language proficiency
sense of belonging and cultural experiences/preferences
Acculturation
relevant to language proficiency and language identity

3.1.5. Primary Outcome

We hypothesize that focus group discussions will provide preliminary information on
how to separate language identity from other overlapping constructs, primarily language pro-
ficiency and acculturation in prior literature. The knowledge gained from these focus groups
will be a useful synopsis for further understanding in the subsequent in-depth interviews.

3.2. Stage 1B: In-Depth Interviews

3.2.1. Study Design
Semi-structured 1-on-1 in-depth interviews will be conducted using English in person
or online at the university in the San Francisco Bay Area. The interviews will emphasize
capturing detailed personal experiences that emerge from comprehensive one-on-one
Int. J. Environ. Res. Public Health 2024, 21, 1311 8 of 19

conversations. Some of the most common Asian languages in the Bay Area are Mandarin,
Cantonese, Tagalog, Vietnamese, Korean, Hindi, Tamil, and Japanese [70,71]. Through
a multilingual research team, we will allocate time and resources for translators and
student interviewers with specific language skills to provide translation services as needed.
The expected duration of each interview will be 60–90 min. An online interview will be
conducted via Zoom (Video Communications, San Jose, CA, USA) for those who are not
able to meet in person. To protect participants’ confidentiality, we will inform them before
beginning the interview that they can choose to use their nickname or a pseudonym in
Zoom as well as choose to turn off their video.

3.2.2. Recruitment
We will recruit a subset of focus group (Stage 1A) participants for the in-depth in-
terviews in this Stage. It is important that focus group participants also join an in-depth
interview to achieve consistent qualitative analysis with the same subjects. We will thor-
oughly explain to participants about the importance of their continued engagement and
commitment to the study. Additionally, after focus group discussions are completed, we
will email preliminary findings (e.g., sharing an executive summary) as well as regular
updates (e.g., news articles about Asian/Asian American immigrant young adults) to
participants for pursuing a high retention rate for in-depth interviews. We aim for approx-
imately 50% of participants from focus group discussions to sequentially join in-depth
interviews. If there are more than 50% of subjects who withdraw from the study after
focus group discussions, we will contact other potential in-depth interview participants.
Approximately a total of 20 young adults will be recruited; thus, there will be 20 in-depth
interviews. As an incentive, a $40 gift card will be provided to all participants.

3.2.3. Data Collection and Data Analysis Process

The same approach as in Stage 1A will be used. The only difference is there will be
20 in-depth interviews. Table 2 outlines the main codes and their subcodes derived from
deductive reasoning, and inductive reasoning will be incorporated from the findings from
in-depth interviews.

Table 2. Stage 1B: Deductive approach for in-depth interviews.

Main Code Subcode

individual English learning and environment from the
home country, early-life English education, individual
Language proficiency perceived language proficiency, individual experience in
the context of language usage, continued discussion
from Stage 1A
individual experience and context for establishing
Language identity language identity, individual ethnocultural identity,
continued discussion from Stage 1A
individual sense of belonging, individual cultural
experiences/preferences relevant to language
Acculturation
proficiency and language identity, continued discussion
from Stage 1A
the degree of concordance, discordance, or expansion
Findings from Stage 1A
with Stage 1A using more detailed subcodes
suggestions and feedback from participants for
Detailed codes
measurement scale development

3.2.4. Primary Outcome

We will gather detailed information about individual language identity through in-
depth interviews, which will focus on the specific experience of interview participants.
Int. J. Environ. Res. Public Health 2024, 21, 1311 9 of 19

This information may either reinforce, support, or present discordance with the findings
from focus group discussions.

4. Stage 2: Quantitative Analysis

Using language identity measurement scale (Stage 2A), a cross-sectional online survey
(Stage 2B) and multivariate multiple linear regression model (Stage 2C), we will determine
the extent to which perceived language proficiency and language identity are associated
with psychological well-being and mental health among 1.5 generation Asian/Asian Amer-
ican young adults.

4.1. Stage 2A: Language Identity Measurement Scale Development

4.1.1. Study Design
In Stage 2A, our objective is to craft a novel language identity measurement scale by
leveraging qualitative insights obtained from both focus group discussions and in-depth
interviews. The process of developing this instrument involves a detailed analysis of
the qualitative data gathered and identification of the most common themes, which will
serve as the foundation for generating scale items. Following the methodology for scale
development validated by DeVellis [72], we will meticulously transform and integrate these
qualitative findings into a comprehensive and robust measurement scale.

4.1.2. Primary Outcome

This scale is intentionally designed to stand apart as a distinct construct from the
conventional notion of perceived language proficiency. This strategic approach ensures
that our measurement scale captures the nuanced facets of language identity, contributing
to a more refined and accurate understanding of this complex construct.

4.2. Stage 2B: Cross-Sectional Online Survey

4.2.1. Study Design
We will design a cross-sectional quantitative, online questionnaire written in English.
We will use validated instruments where possible, and include the new measurement
scale for language identity developed in Stage 1, to measure independent and dependent
variables of interest, including perceived language proficiency, language identity, anti-Asian
hate crime victimization, ethnocultural identity confusion, acculturative stress, racism and
discrimination, psychological well-being, and mental health, as well as demographic
information among 1.5 generation Asian/Asian American young adults.

4.2.2. Sample Size Justification

We will reach out to approximately 600 survey participants (1.5 generation Asian/Asian
American immigrant young adults) as a sampling frame, which will allow us to estimate the
outcome of interest from the representative of the target population. Using G*Power 3.1 [73],
given an anticipated F-squared effect size of 0.15, α of 0.05, Power (1–β) of 0.8, and predictors
(independent variables, including mediator variables), the minimum required sample size for
finding statistical significance is 146 participants, which will give us a response rate of 24.3%
(146/600). This sample size expectation may be adjusted once we complete the survey design
and make final decisions on instrumentation. To increase the completion rate, participants
will be recontacted if they initiated but did not complete the survey.

4.2.3. Recruitment
The same recruitment strategy will be used as in Stage 1, but the catchment area will be
expanded to the San Francisco Bay Area. Because the criteria are very specific to variables
associated with lower response rates (e.g., race, exposure to English, age, family type, the
period of residence in the U.S., and geography), there could be challenges in reaching the
desired sample size; thus, our online survey will be distributed to all 57 higher education
institutions—across the University of California, California State University, the California
Int. J. Environ. Res. Public Health 2024, 21, 1311 10 of 19

Community Colleges, private nonprofits, and private for-profits—and 23 identified organiza-

tions for young adults located in 9 counties of the Bay Area (Alameda: 19, Contra Costa: 4,
Marin: 3, Napa: 2, San Francisco: 22, San Mateo: 5, Santa Clara: 17, Solano: 4, and Sonoma:
4) (Supplementary Materials Table S1). A $10 gift card will be provided to participants who
complete the online survey.

4.2.4. Data Collection

We will use Qualtricsxm (Qualtrics International Inc., Provo, UT, USA) to collect
online survey data, and then store quantitative data in Google Shared Drive (Google Inc.,
Mountain View, CA, USA), which are both exclusively for research team members to protect
data confidentiality.

4.2.5. Measurement
The survey will consist of 9 main categories: (1) demographic information (con-
founders), (2) self-perceptions of language proficiency in the languages that participants are
exposed to (independent variable I), (3) language identity (newly developed from Stage 1;
independent variable II), (4) ethnic identity (mediator I), (5) acculturative stress (mediator
II), (6) racism and discrimination (mediator III), (7) anti-Asian hate crime victimization
(moderator), (8) psychological well-being for satisfaction/optimism levels of adjustment in
the U.S. (dependent variable I), and (9) mental health (dependent variable II). For demo-
graphic information, the country of origin, current age, age of arrival, length of time in the
U.S., gender, socioeconomic status, family type, place of residence, religion, educational
attainment, family background, and learning environment will be collected. Participants’
perceived language skills in their languages will be measured through a published self-
report classification tool [74] and the Language Experience and Proficiency Questionnaire
(LEAP-Q) [75]. To assess language identity, we will use our version of a language iden-
tity measurement scale developed in Stage 1. Ethnocultural identity confusion will be
measured using the Ethnic Identity Scale (EIS) [76] and the Multigroup Ethnic Identity
Measure-Revised (MEIM-R) [77]. To measure acculturative stress due to L2 learning for
adjustment to U.S. society, the Demands of Immigration Scale (DIS) [78] will be used, which
measures demands related to immigration, occupational adjustment, language accommo-
dation, discrimination, and resettlement issues. For measuring racism and discrimination,
the +20-item Perceived Discrimination Scales [79] will be used. Regarding anti-Asian hate
crime victimization, we will use the National Crime Victimization Survey (NCVS) [80],
modifying it specifically for Asians/Asian Americans. The Ryffs Scales of Psychological
Wellbeing-54 [81] will be used for well-being measurement. Mental health disparities will
be assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D) [82],
the Patient Health Questionnaire-9 (PHQ-9) [83], and the Generalized Anxiety Disorder-7
(GAD-7) [84]. To measure participants’ experiences related to the pandemic, we will add a
quantitative measurement scale, II. Coronavirus (COVID-19) Pandemic section from the
Baylor Religion Survey (Wave 6, 2021) [85], to our survey. Table 3 displays variable types,
constructs, and measurement names.

Table 3. Stage 2B: The use of constructs and their measurements.

Variable Type Construct Measurement Name

Demographic information (confounders) Not applicable Not applicable
Self-report classification tool [74] and
Independent variable I Perceived language proficiency Language Experience and Proficiency
Questionnaire (LEAP-Q) [75]
Newly developed measurement scale
Independent variable II Language identity
from Stage 1
Int. J. Environ. Res. Public Health 2024, 21, 1311 11 of 19

Table 3. Cont.

Variable Type Construct Measurement Name

Ethnic Identity Scale (EIS) [76] and
Mediator I Ethnic identity Multigroup Ethnic Identity
Measure-Revised (MEIM-R) [77]
Mediator II Acculturative stress Demands of Immigration Scale (DIS) [78]
+20-item Perceived Discrimination
Mediator III Racism and discrimination
Scales [79]
National Crime Victimization Survey
Moderator Anti-Asian hate crime victimization
(NCVS) [80]
Ryffs Scales of Psychological
Dependent variable I Psychological well-being
Wellbeing-54 [81]
Center for Epidemiologic
Studies-Depression Scale (CES-D) [82],
Dependent variable II Mental health Patient Health Questionnaire-9
(PHQ-9) [83], and Generalized Anxiety
Disorder-7 (GAD-7) [84].

4.2.6. Data Analysis

To analyze quantitative data collected from the online survey for a descriptive cross-
sectional study, we will use a quantitative analysis software, Stata/MP 18.0. The data
used for analysis will be separated from identifying information (i.e., email addresses).
Only an ID number will be used on surveys. Our analysis will primarily aim to ascertain
if language identity and perceived language proficiency are separate concepts and to
measure quantitative variables related to interests and demographic information among
1.5 generation Asian/Asian American young adults.

4.2.7. Primary Outcome

We expect to design the survey with relevant measurements and collect data from the
target sample size. We will collect data regarding both perceived language proficiency and
language identity. In addition, designing the online survey will allow us to measure the
association between perceived language proficiency/language identity and psychological
well-being/mental health disparities of 1.5 generation Asian/Asian American immigrant
young adults in the Bay Area, California for the next step, Stage 2B.

4.3. Stage 2C: Multivariate Multiple Linear Regression Analysis

4.3.1. Study Design
Using the multivariate multiple linear regression model through the Ordinary Least
Squares (OLS) regression technique, we will measure two dependent variables, psycho-
logical well-being and mental health, and their relationship to two independent variables,
perceived language proficiency and language identity in multilingual individuals among
our target population. To explore the hypothesis that language identity is associated with
individual differences in psychological well-being and mental health disparities, we will
examine the extent to which acculturative stress (cultural disorientation), and racism and
discrimination mediate this association. Figure 3 demonstrates the possible finding that
young adults who report weaker self-perceived language skills in the dominant language
(English) and a lower sense of language identity (L1 and L2) (independent variables) will
be more susceptible to ethnocultural identity confusion, acculturative stress, and racism
and discrimination, leading to separation or marginalization from society (mediators) (Path
a), which would ultimately result in disparities in psychological well-being and mental
health (dependent variables) (Path c). Anti-Asian hate crime victimization will be treated
as a moderator (effect-modifier) (Path b), acting between the independent variable and
the mediator. Additionally, we will investigate a possible direct pathway between the
 be more susceptible to ethnocultural identity confusion, acculturative stress, and racism
and discrimination, leading to separation or marginalization from society (mediators)
(Path a), which would ultimately result in disparities in psychological well-being and
Int. J. Environ. Res. Public Health 2024,mental
21, 1311 health (dependent variables) (Path c). Anti-Asian hate crime victimization will 12 of be
19
treated as a moderator (effect-modifier) (Path b), acting between the independent variable
and the mediator. Additionally, we will investigate a possible direct pathway between the
independent
independent and anddependent
dependent variables
variables (Path
(Path d). Using
d). Using the product-of-coefficients
the product-of-coefficients ap-
approach,
proach, we will explore the indirect effects of an independent variable on
we will explore the indirect effects of an independent variable on a dependent variable a dependent
variable athrough
through mediator a mediator variable
variable as as apoint.
a starting starting point.
Then, weThen, we awill
will use use a sophisticated
sophisticated method,
method,
the the bias-corrected
bias-corrected bootstrapping,
bootstrapping, to obtainto obtain
more more accurate
accurate estimatesestimates of the signif-
of the significance of
icance of mediated
mediated effects
effects in the in the proposed
proposed sample (nsample
= 146). (n = 146).

Figure 3. Possible
Figure Possiblepath
pathmodel
modelofof
thethe
association between
association perceived
between language
perceived proficiency
language and and
proficiency lan-
guage identity and health disparities and mental health conditions with mediators.
language identity and health disparities and mental health conditions with mediators.

4.3.2.
4.3.2. Data Analysis
The
The same
same approach
approachas
asthe
thecross-sectional
cross-sectionalonline
onlinestudy forfor
study thethe
quantitative analysis
quantitative of
analysis
OLS
of OLSwillwill
be be
used.
used.

4.3.3.
4.3.3. Primary
Primary Outcome
Outcome
We aim to disentangle the previously confounded constructs from the existing per-
We aim to disentangle the previously confounded constructs from the existing per-
ceived language proficiency and the newly developed language identity scales from Stage 1
ceived language proficiency and the newly developed language identity scales from Stage
by employing those two distinct measures. We will assess whether the two constructs,
1 by employing those two distinct measures. We will assess whether the two constructs,
perceived language proficiency and language identity, make distinct contributions to psy-
perceived language proficiency and language identity, make distinct contributions to psy-
chological well-being/mental health. This approach will allow us to examine the potential
chological well-being/mental health. This approach will allow us to examine the potential
differential effects of these two language-related constructs on psychological well-being
differential effects of these two language-related constructs on psychological well-being
and mental health disparities in 1.5 generation Asian/Asian American immigrant young
and mental health disparities in 1.5 generation Asian/Asian American immigrant young
adults in the Bay Area, California. Analyses of the effects of potential mediator variables,
adults in the Bay Area, California. Analyses of the effects of potential mediator variables,
including ethnocultural identity confusion, acculturative stress, racism, and discrimination,
including ethnocultural identity confusion, acculturative stress, racism, and discrimina-
will be presented. Additionally, we will measure the moderating effect of the variable
tion, will be presented. Additionally, we will measure the moderating effect of the variable
anti-Asian hate crime victimization, which may influence the magnitude of the relationship
anti-Asian
between thehate crime victimization,
independent and moderatorwhich may influence the magnitude of the relation-
variables.
ship between the independent and moderator variables.
5. Stage 3: Qualitative Analysis
5. Stage 3: Qualitative Analysis
Subsequent in-depth interviews will be conducted to flesh out contextual information
Subsequent
and patterns in-depth about
of experience interviews will be conducted
the cross-sectional to flesh
information out contextual
examined infor-
in the quantita-
tive analysis, using a subsample of quantitative survey respondents in Stage 2. Based the
mation and patterns of experience about the cross-sectional information examined in on
quantitative
their analysis, using
survey responses, a subsample
we will seek to gainof anquantitative survey respondents
in-depth understanding in Stage
of experiences 2.
with
Based on theirand
acculturation survey responses,and
discrimination we how
will seek
thesetoexperiences
gain an in-depth understanding
relate to of expe-
their own perceptions
riences
of withskills
language acculturation and discrimination
and psychological and howhealth
well-being/mental these experiences relate
(Stage 3A). An to their
analysis of
own perceptions
qualitative of provide
data will languagefurther
skills context
and psychological well-being/mental
around the statistical results ofhealth (Stage
the quantita-
tive analysis [86]. Translation support for those who note that they prefer a bicultural or
bilingual interviewers will be provided, just as in Stage 1.
Int. J. Environ. Res. Public Health 2024, 21, 1311 13 of 19

5.1. Stage 3A: Follow-Up In-Depth Chronological Interviews

5.1.1. Study Design
The follow-up semi-structured, chronological interviews (life history format) will
be conducted sequentially with a subset of survey participants using their preferred lan-
guages. Interviews are expected to have the same duration as in Stage 1B, lasting between
60 and 90 min. These interviews aim to enhance our understanding of the quantitative
association between perceived language proficiency/language identity and psychological
well-being/mental health disparities. Through gathering unique information from indi-
vidual narratives, these interviews will provide data on the actual individual trajectories
illustrating how language proficiency and language identity are connected to mental health
and psychological well-being. The methods for conducting interviews will be the same as
Stage 1B.

5.1.2. Recruitment
The recruitment area will be expanded from Santa Clara County, used in Stage 1, to the
San Francisco Bay Area, Northern California, as it is for the survey. There will be two dif-
ferent groups: (1) a group that reported mental health consequences, and (2) a group did
not report mental health issues. Approximately 20 young adults who completed the online
survey will be recruited, and there will be 20 in-depth interviews, 10 participants from
one group and the other 10 participants from the other group. We will choose participants
selectively to obtain well-balanced samples that reflect our various demographic variables,
such as age range and the distribution of countries of origin [68]. An incentive of $40 gift
cards will be provided to all participants, and additionally, to encourage participants to
join an interview, a transportation voucher of up to $30 will be provided for those who live
farther than 57 miles from the study location—this is the average distance from all 80 target
institutions/organizations to the main study location.

5.1.3. Data Analysis Process

We will use the same approach as in Stage 1 using a deductive/inductive approach.
Table 4 shows the deductive approach in this planning stage, to which inductive approach
coding will occur after the completion of in-depth interviews. These transcripts, however,
will be longer and more extensive than in Stage 1 because we will pursue life history, asking
participants to discuss a chronology of life (and language use) as a 1.5 generation immigrant.

Table 4. Stage 3A: Deductive approach for in-depth life history interviews.

Main Code Subcode

perceived language proficiency, category for use
Multilingualism
(when they use what)
perceived language identity related to actual
Identity
language usage, ethnocultural identity
Anti-Asian hate crime victimization experience before, during, and after COVID-19
fear, guilt, mood, acculturation stress, cultureshock,
Acculturation
homesickness, emotional neglect
experience with anti-Asian hate crimes, perceived
Racism/Discrimination
hatred/rejection/discrimination
relationship with others, happiness, personal
growth, self-acceptance, purpose in life,
Psychological well-being
environment, social support, accomplishment,
life satisfaction
Int. J. Environ. Res. Public Health 2024, 21, 1311 14 of 19

Table 4. Cont.

Main Code Subcode

self-deprecation, stress, anxiety, insomnia,
addiction, substance abuse, depression,
Mental health disparities
post-migration trauma, relation to
language identity
benefits of multilingual, confidence in life,
Opportunities
resource sharing
asking for needed support, intervention programs
Heading for the future
for the future studies

5.1.4. Primary Outcome

We expect that in-depth interviews will confirm the association between perceived
language proficiency/identity and psychological well-being/mental health disparities
identified in Stage 2. In-depth interviews will strengthen the findings through unique
individual narratives that were not captured in Stage 2.

5.2. Ethical Considerations

We will use Qualtricsxm (Qualtrics International Inc., Provo, UT, USA), Stata/MP 18.0
(StataCorp, College Station, TX, USA) and NVivo (QSR International, Pty, Ltd., Doncaster,
Australia) to collect, manage, and analyze data, and then store them in the Google Shared
Drive (Google Inc., Mountain View, CA, USA), which are both exclusively for research
team members to protect data confidentiality. There will be four consent notices (written
consent electronic English documents, participant’s signature not required). Once they
confirm their intent to participate by replying to our request via email, a separate consent
form PDF document for a focus group discussion will be emailed to them as a reminder, at
least 24 h prior to each discussion (Stage 1A). The in-depth interview consent notice will be
administered right after the focus group discussions (Stage 1B). There will be a standard
consent notice for an online survey, embedded at the beginning of the Qualtrics survey as
electronic texts (Stage 2A). Participants’ email addresses used for the recruitment of focus
group and in-depth interview participants (a subsample of quantitative survey participants)
will be collected as a sole identifier. Email information will be kept in a separate encrypted
file. Those who fill in the online survey will be asked whether they can join an in-depth
interview (Stage 3A). A standard consent form will be provided to participants at least 24 h
prior to an in-depth interview.

6. Discussion
6.1. How the Proposed Research Would Shift Current Research Paradigms
This proposed research and its methodology is innovative because it will be the first
to investigate how the constructs of perceived language proficiency and language identity
can link to a sense of belonging, psychological well-being, and mental health among
multilingual 1.5 generation Asian/Asian American immigrant young adults, who are
vulnerable to becoming victims of anti-Asian hate crimes. Moreover, immigrant-tailored
social adjustment strategies for feelings of acceptance in American society associated
with learning an L2 have not been substantially discussed. This specific circumstance of
multilingualism presents unique sociocultural benefits (i.e., a multilingual and multicultural
worldview), but also unique challenges to learning more than one language under strong
societal norms and pressures when there is a new dominant language and new culture.
Ultimately, we expect this study will be the cornerstone of establishing culturally tailored
multilingual education for Asian/Asian American immigrant young adults’ strong sense
of acceptance, inclusion, identity, and psychological well-being/mental health in the U.S.
Int. J. Environ. Res. Public Health 2024, 21, 1311 15 of 19

6.2. Contribution to the Field of Mixed Methods Research

Collectively, this study protocol uses an innovative approach because it uses a newly
developed three-step mixed methods approach (Stage 1: qualitative, Stage 2: quantita-
tive, and Stage 3: qualitative), representing a significant advancement from traditional
explanatory or exploratory sequential designs. By integrating qualitative and quantitative
analyses in a systematic and iterative manner, this study addresses several methodological
gaps and offers new insights that advance the field. Additionally, in reflecting upon the
literature reviewed in the background section, this study bridges the gap between qualita-
tive explorations of language identity and quantitative assessments, providing a coherent
and integrated methodological approach. It demonstrates the value of sequential mixed
methods designs in developing and validating measurement scales, and in elucidating
complex relationships between psychosocial constructs.
Overall, this study advances the field of mixed methods research by offering a multiple-
step methodological framework for studying language identity and its relationship with
mental health among 1.5 generation Asian/Asian American immigrant young adults in one
state in the U.S., with future hopes to further validate our sample to broader U.S. 1.5 gener-
ation Asian/Asian American population. The findings of this study prompt a reevaluation
of how language identity is conceptualized and measured, ultimately contributing to a
deeper and more comprehensive understanding of identity formation in multicultural and
multilingual settings.

6.3. Limitations
This research encounters a few limitations. Firstly, our inclusion criteria for recruiting
potential participants who fit the definition of the 1.5 generation are stringent, requiring
additional effort to identify suitable candidates. Specifically, participants must be Asian
or Asian American young adults residing in the San Francisco Bay Area, who arrived in
the U.S. with their first-generation parents between the ages of 5 and 17, have resided in
the U.S. for at least 12 months, and currently fall within the age range of 18 to 29 years.
While the anticipated number of 40 participants in the focus group discussions in Stage 1A
and the minimum sample size of 146 participants in Stage 2B align with the consideration
of potential challenges in identifying eligible participants, they may still present certain
difficulties in fully validating this long-term protocol. Additionally, achieving thematic
saturation and managing potential subjective variability might be areas to carefully monitor
with the anticipated sample size for the Stage 1A focus group discussions and the Stage 2C
survey analyses. Secondly, the geographic scope of our participant pool is confined to the
San Francisco Bay Area in California, thereby limiting the representativeness of the broader
1.5 generation Asian/Asian American young adult population in California and across
the U.S. A more geographically diverse sample can be considered throughout the study
protocol to increase the validity of the study.

6.4. Recommendations for Future Mixed Methods Inquiry

By moving beyond traditional exploratory or explanatory sequential designs to a three-
step sequential mixed methods design, researchers can maximize the strengths of both
qualitative and quantitative methods, thereby advancing knowledge and understanding in
their respective fields. Researchers and methodologists are encouraged to look into this
approach to other research contexts, recognizing the value of integrating qualitative and
quantitative analyses in a sequential and iterative manner.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph21101311/s1, Table S1. List of higher education institutions
in the San Francisco Bay Area.
Int. J. Environ. Res. Public Health 2024, 21, 1311 16 of 19

Funding: Research reported in this publication was supported by the National Institute of General
Medical Sciences of the National Institutes of Health under Award Number R16GM150715. The
content is solely the responsibility of the authors and does not necessarily represent the official views
of the National Institutes of Health.
Institutional Review Board Statement: This study was approved by San José State University’s
Institutional Review Board. Type of review was an exempt registration: Category of approval
§46.104(d)(2iii) (IRB Number: 23105).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data sharing is not applicable to this article as no datasets were
generated or analyzed during the current study.
Conflicts of Interest: The authors declare that they have no competing interests.

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