Journal of Cross-Cultural Gerontology 11: 131-147, 1996. (~) 1996 Kluwer Academic Publishers. Printed in the Netherlands.
Correlates of psychological distress among Mexican, Cuban, and Puerto Rican elders living in the USA A D A C. M U I Columbia University, New York, USA
Abstract. Little is known about the impact of coping resources and health-related and family stresses on the well-being of Hispanic elders, or the extent to which these factors operate differentially for various Hispanic nationality groups. The present study examined the correlates of psychological distress of three groups of Hispanic elders. The researcher analyzed the Mexican American (n = 773) Cuban American (n = 714), and Puerto Rican (n = 368) elderly individuals drawn from the 1988 National Survey of Hispanic Elderly People in the USA. Multivariate analyses results indicated that activities of daily living impairments, poor perceived health, and unmet needs in formal social service were common predictors of psychological distress for all three groups. Older Mexican American women and Puerto Rican women reported higher levels of psychological distress than their male counterparts, other things being equal. For Cuban American elders, fear of depending too much on others, conflicts in the family, and living alone were unique predictors of their psychological distress. Key words: Stress, Coping, Psychological well-being, Mexican Americans, Cuban Americans, Puerto Rican Americans, USA
Introduction Hispanic elders in the USA are not a homogeneous group. They differ by country, region o f origin, cultural background, degree o f acculturation, socioeconomic class, education level, migration history, and political ideology. Research has usually ignored the ethnic variation among the Hispanic elderly population and has lumped them together as if they are a homogeneous group (Mui 1993; Mui & Bumette 1994). At present, about 5% o f all persons aged 65 and over are Hispanic, and this group is one o f the fastest growing populations nationwide (US Bureau o f Census 1990). It is estimated that while the older white population is expected to grow by 92% between 1990 and 2030, the projected increase for older Hispanics is 395% (US Senate Special Committee on Aging 1991). Some gerontologists suggest that the stresses o f immigration, acculturation, poverty, illnesses, functional impairments, and weakening family support may be sources o f their poor health and psychological distress (Gelfand & Yee 1991; Mahard 1988).
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This study used data from the 1988 National Survey of Hispanic Elderly People to examine the correlates of psychological well-being among older Mexican Americans, Cuban Americans, and Puerto Ricans. The first objective of this study was to determine the roles that health-related and family stresses and coping resources play in predicting well-being. A second objective was to determine if these relationships differed among Hispanic nationality groups.
Literature review
Recent research has begun to document the serious financial, health, and psychological problems that Hispanic elders face in the USA (e.g., Andrews, Lyons & Rowland 1992; Angel & Angel 1992; Bastida 1984; Krause & Goldenhar 1992). These studies confirm that Hispanic elders experience both the absolute and relative disadvantages suffered by most older ethnic minority groups. For example, in comparing a national random sample of all older Americans (Commonwealth Fund 1989) with Hispanic elderly persons in a companion data set (Westat 1989), Andrews, Lyons & Rowland (1992) found that Hispanic elders fared worse on almost all major dimensions of health and well-being, particularly on measures of income, command of English, educational attainment, and functional status. Research evidence also indicates that racial and ethnic minorities experience more psychological distress than majority Americans (Kemp, Staples & Lopez-Aqueres 1987; Kessler & Neighbors 1986). Ethnic minority status is associated with low income, minimal education, substandard housing, and lack of opportunity (Markides & Mindel 1987). Ethnic minority elders living under these conditions not only experience more strain and stress but often have fewer social and psychological coping resources (Kulys 1990). Some researchers have examined the role of cultural assimilation in understanding the health behavior of these elders (Marks, Solis, Richardson, Collins, Birba & Hisserich 1987). Findings showed that after controlling for education and age, no dimension of assimilation was associated with health behavior. These findings suggest that factors other than assimilation, such as access to and availability of services, the adequacy of informal support, and sociodemographic characteristics may be stronger determinants of Hispanic health practices. Researchers have also studied the role of informal support systems, particularly family members, and their impact on the mental and physical wellbeing of ethnic elders (Cantor 1979, Lubben & Becerra 1987). Findings are mixed. Several studies found that social support systems can mediate the impact of stress among the elderly (Arling 1987; Husaini, Moore, Castor, Whitten-Stovall, Linn & Griggin 1991; Noms & Murrell 1984). However,
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other evidence indicated that family support can be a source of psychological distress among the elderly (e.g., Rook 1984). For example, some research on Hispanic elders indicated that health problems and increased family support were associated with depression (Kemp et al. 1987; Mahard 1988). Markides & Krause (1985) found that high levels of family interaction were associated with greater depression among older Mexicans. By and large, studies on Hispanic family support have shown consistently that Hispanic elders have stronger bonds with family members and higher levels of interaction and support from children, than either black or white elders, controlling for gender and social class (Cantor 1979; Lubben & Becerra 1987). Furthermore, there is a strong sense of family obligation that often supersedes the needs of individual family members. Hispanic elders also expect their family to assist them in their old age and treat them with respect (Markides & Krause 1985). These studies suggest that there is an ethnic factor in family social support. Some differences in family support and services use among ethnic groups can be attributed to culture, socioeconomic status, and immigration patterns (Linn, Hunter & Perry 1979; Markides & Mindel 1987). Family supports and formal services use also may vary greatly according to the degree of acculturation (Vaux 1985). This may be especially true among Hispanic elders, over 50% of whom came from abroad (Biafora & Longino 1990). Some evidence has suggested that there are differences in family support among Hispanic subgroups. Older Cuban Americans generally have sought only the help of their children and not that of other family members (Escovar & Kurtines 1983). Among Mexican Americans, there has been a high level of exchange and reciprocity between generations of children and grandchildren (Markides & Krause 1986). Puerto Rican elders, unlike Mexican Americans, Cuban Americans, and other Hispanics, have relied on themselves and friends for assistance more than on family members (Lacayo & Crawford 1980). Association between family members and Hispanic elders may not always be beneficial for elders. As stated above, research has indicated that increased association of older Mexican Americans with their children was related to an increase in the elders' depression (Markides & Krause 1985, 1986). These data suggest that family contact can become a source of stress. In this study, the impact of health-related and family stresses on the psychological wellbeing among the three groups of Hispanic elders was examined. Most researchers have ignored the diverse cultural, historical, demographic and ecological conditions of Hispanic subnational groups in the USA (Aguirre & Bigelow 1983), merging Mexican Americans, Cuban Americans, and Puerto Ricans into one 'Hispanic' category. Recent large national studies of Hispanic elders that used inferential statistical models to examine dif-
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ferences among and within Hispanic subgroups revealed substantial group variations. Group variations were also associated with differential patterns of family dynamics, service need, and preference for formal service use (Starrett, Todd & De Leon 1989; Starrett, Wright, Mindel & Tran 1989). In this study, a stress and coping framework (Aldwin 1994; Lazarus & Folkman 1984) was used to conceptualize and examine the relation between stresses, coping resources and psychological well-being outcome for Hispanic elders. The stress and coping framework acknowledges the importance of personal and environmental stress, such as family conflicts, and their effects on elders' overall well-being (Aldwin 1994; Mui 1993). Methods for coping with stress are determined by cognitive appraisal and include both cognitive and behavioral efforts to manage stresses that are appraised as taxing. Coping resources usually include physical, psychological, spiritual, social skills, and social supports that are available to an individual (Burnette & Mui 1994; Lazarus & Folkman 1984; Mui 1993). Theoretically, there are at least two possible ways in which coping can affect well-being outcomes. First, there may be direct effects on well-being measures. Second, the coping strategies may moderate or buffer the effect of stress on well-being outcomes (Aldwin 1994). In this study, both additive and interactive effects of stress and coping resources were tested with the whole Hispanic elderly sample. In addition, the author also tested group differences among Hispanic nationality groups in the stress and coping process. Therefore, three hypotheses were tested: H1 Stress factors and coping resources have significant additive effects on the psychological well-being of Hispanic elders. H2 Stress and coping resource factors have interactive effects with nationality groups on the level of psychological well-being. H3 Correlates of psychological well-being are different for the three groups of Hispanic elders.
Methods
Sample and data sources
Data are from the 1988 National Survey of Hispanic Elderly People. The study, a part of the Commonwealth Fund Commission's project on elderly people living alone (Commonwealth Fund 1989), used a telephone survey to obtain a profile of the health, economic, and social circumstances of Hispanic people aged 65 and over. Between August and October 1988, trained, bilingual interviewers gathered information on living arrangements, length of time living in the USA, economic resources, health and functional status, social network, family support, and psychological well-being (Davis 1990).
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The survey provides a nationally representative sample of Hispanics age 65 and over, living within telephone exchanges with at least 30% concentrations of Hispanic residents in three geographic areas in the continental USA. Using random digit dialing, 48,183 households were screened for Hispanics aged 65 and over, resulting in completed interviews of 2,299 older Hispanics. The overall response rate was 80%. Eighty-seven percent of interviewees chose to be interviewed in Spanish. The analyses presented in this paper are based on a subsample (unweighted numbers) of Mexican Americans (n = 773), Cuban Americans (n = 714) and Puerto Ricans (n = 368). Other Hispanic groups were not included because their numbers were limited. Almost all the Cuban American (99%) and Puerto Rican elders (98%), but only 42% of the Mexican American elders were foreign born. Measures Outcome variables. Psychological distress was assessed by self-reported experiences in the last few weeks of feeling restless, remote from other people, bored, depressed, upset, lonely, and anxious (each coded dichotomously). A principal components analysis with varimax rotation was performed and a one-factor solution was identified. The seven items were summed to create a composite score of psychological distress (Cronbach alpha = 0.76). The first five items are comparable to the negative affect items in the Affective-Balance Scale (Bradbum 1969). Independent variables. Based on the literature review and stress and coping framework, the independent variables were conceptualized and categorized into sociodemographic, health-related, personal and family stresses, and coping resources factors. With regard to sociodemographic variables, receipt of public assistance was treated as a proxy measure of income because the income variable was not usable due to excessive missing data. Age, sex, education, living arrangements, and length of stay in USA (as an indicator of acculturation) were included as controls so that the effects on stress and coping resources factors could be assessed. Two dummy variables, Mexican American and Puerto Rican, were created in order to examine between group differences in the interactive model, with persons of Cuban ancestry serving as the reference group, which is consistent with the literature (Bumette & Mui 1995; Krause & Goldenhar 1992). Health-related, personal, and family stress factors included Activity of Daily Living (ADL) impairment, perceived health, number of doctor visits, hospital use, fear of dependence, caregiving duty, family conflicts, financial strain, and unmet needs in formal services. Previous research has shown that these three groups of Hispanic elders differ greatly in migration experience,
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lengths of stay in the USA, levels of acculturation, education, and socioeconomic status (e.g., Angel & Angel 1992, Bean & Tienda 19873. These group differences may translate into differential health status in late life which might be associated with their perceived psychological distress. For these Hispanic elders, the combined effects of language barriers, financial strain, aging, health deterioration, functional impairment, and adjustments to the demands of health care system, may prove particularly stressful. English language ability, number of children, frequency of contact with children, with friends, church, and utilization of in-home and communitybased services were conceptualized as coping resources available to these Hispanic elders. English language proficiency, which varies by level of education, age of immigration, and nationality was used as a proxy for acculturation (Angel & Angel 1992; Krause & Goldenhar 1992). Family, friends, and church support are significant emotional and instrumental resources. Despite disadvantages associated with low income, low educational attainment, English language deficits, and poorer health status, older Hispanics, like most other older ethnic elders, tend to underutilize formal services (Greene & Monahan 1984). Service use is a complex behavior associated with factors such as kin as well as service availability, accessibility, and cultural acceptability (Burnette & Mui 1995).
Results
Description of sample Descriptive statistics were used to generate a sociodemographic profile of the three groups of Hispanic elders. Table 1 presents a descriptive profile of the three groups of Hispanic elderly people. These data show that the Hispanic elderly population, as suggested above, is not a homogenous group. About one-fifth of the Mexican and Cuban Americans were aged 80 or older, making them somewhat older than the Puerto Ricans. Cuban American elders fared better than either of the other two groups. Puerto Rican eiders were more likely than the other two groups to fall below the poverty line (41.1%) and fewer Puerto Ricans had private insurance. In addition, nearly two-thirds of the Puerto Rican elders were unmarried (compared to fewer than half of the other groups), and nearly twice the percentage of this group lived alone. Cuban Americans had the least command of English language skills, indicating that they may be less assimilated. Furthermore, both Puerto Rican and Mexican American elders had completed fewer years of education than Cuban American elders. More than 80% of the Puerto Rican and Mexican American elders had not graduated from high school while 18% of the Cuban
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Table 1. Sociodemographic characteristics of three groups of Hispanic elders (in %) Mexican American (N = 773) ~
Age . . . . 65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 and over Mean Age Gender Female Marital status Married . . . . Education . . . . Grade school or less High school College or more Living arrangement . . . . Alone With others SSI Private insurance . . . . Self-rated English language skills Able to speak . . . . Able to read . . . . Able to write . . . . Length of stay in the US. . . . Household income . . . . $ 5,500 or less $ 5,501-15,000 $15,001 or more
37.7 23.0 18.6 13.7 7.0 73.1
Cuban American (N = 714) ~ Percentagesp 32.3 23.9 22.7 12.8 8.3 74.3
Puerto Rican (N = 368) ~
39.9 24.2 19.6 9.5 6.8 72.2
62.5
62.5
66.6
51.1
53.1
34.1
81.6 15.3 3.1
59.2 23.0 17.8
84.0 12.2 3.8
22.1 77.9 12.2 27.9
21.0 79.0 13.2 31.8
36.7 63.3 16.5 16.3
46.3 56.3 44.9 47.6
36.7 43.4 34.5 24.0
51.4 51.9 41.0 38.2
36.6 51.4 12.0
35.1 44.5 20.4
41.5 47.6 10.9
Note: Chi-square statistic was used. ~Unweighted numbers. VPercents based on unweighted numbers. . . . . p < 0.0001.
A m e r i c a n e l d e r s h a d a c o l l e g e l e v e l e d u c a t i o n . T h e first t w o g r o u p s a l s o h a d t w i c e as m a n y c h i l d r e n as did C u b a n A m e r i c a n elders, i n d i c a t i n g s u b s t a n t i a l l y h i g h e r fertility. T a b l e 2 p r e s e n t s th e m e a n s a n d s t a n d a r d d e v i a t i o n s o f all m a j o r v a r i a b l e s in t h e m u l t i p l e r e g r e s s i o n m o d e l s . T h e s e d a t a s h o w that C u b a n A m e r i c a n a n d M e x i c a n A m e r i c a n e l d e r s h a d less p s y c h o l o g i c a l d i s t r e s s than P u e r t o
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Table 2. Means and standard deviation of major variables Mexican American (N = 773)
Psychological distress items Restless**** Remote*** Bored**** Depressed* Upset* Lonely Anxiety*
Cuban American (N = 714)
Puerto Rican (N = 368)
Percentages 22.3 36.9 22.6 33.2 23.9 37.5 27.7 35.9 8.1 11.7 21.6 26.9 37.5 45.7 Means (standard deviation) 1.83 (1.91) a 1.64 (1.81) ~ 2.28 (2.15) b 23.7 25.2 26.8 29.1 11.8 23.8 42.2
Psychological distress (Composite score: 1-7) Health-related stresses ADL impairments (1-7) Self-perceived health (1-4) Doctor visits (per year) Hospital use (yes = 1) Personal and family stresses Fear of dependence (yes = 1) Caregiving duty (yes = 1) Family conflicts (yes = 1) Financial strain (yes = I) Unmet needs (0-9) Coping resources English ability (0-3) Number of children Children contacts (per week) Friend contacts (yes = 1) Church contacts (yes = 1) In-home service use (0-4) Community-based use (0-5)
1.41 2.42 6.39 0.21
(1.10) ~ (0.86) '~ (7.53) a (0.41) a
0.82 2.62 8.03 0.23
(1.00) b (0.86) b (9.99) b (0.42) a
1.39 2.31 11.65 0.30
(1.45) c (0.84) c (9.81) c (0.45) b
0.32 0.21 0.22 0.80 2.13
(0.46) a (0.40) a (0.41) a (0.80) ~ (2.14) a
0.26 0.16 0.17 0.52 1.35
(0.43) b (0.36) b (0.37) b (0.70) b (2.10) b
0.27 0.20 0.25 0.66 2.11
(0.44) b (0.40) ~ (0.43) c (0.75) c (2.10) a
1.47 4.64 2.51 0.61 0.40 0.28 0.49
(1.22) a (3.26) a (1.80) a (0.21) a (0.32) '~ (0.18) ~ (0.36) ~
1.15 2.05 1.58 0.46 0.49 0.23 0.43
(1.31) b (1.68) b (1.58) b (0.11) b (0.32) b (0.19) ~ (0.37) ~
1.44 3.81 1.31 0.47 0.37 0.44 0.68
(1.28) a (2.88) c (0.83) b (0.23) b (0.11) c (0.30) b (0.31) b
Note: Chi-square statistics were used to test the proportion differences. ANOVA statistics with post hoc multiple comparisons were used to test the differences among means. Means with the different letters are significantly different at less than the 0.05 level in the same variable. *p < 0.05; ***p < 0.001; . . . . p < 0.0001.
Rican elders. Among the health-related and family stress factors, Cuban American elders had better self-perceived health and less financial strain than their Mexican
American
and Puerto Rican counterparts.
Cuban
American
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elders were also least impaired in ADL. They also reported fewer unmet service needs, caregiving responsibilities, and family conflicts. In terms of coping resources, including the two types of formal service use (in-home and community-based) and informal network variables for the three subgroups, Puerto Rican eiders reported a much higher use of in-home and communitybased services than the other two groups. Mexican American elders reported having more living children and more frequent contact with children each week.
Multivariate analyses Hierarchical regression analyses were conducted to test the three hypotheses. For the first two hypotheses, a simple additive model and a model with additive and interactive effects were used to test the differential impacts of stress and coping factors on psychological well-being of Hispanic elders. For the third hypothesis, three separate hierarchical regressions for the three groups of Hispanic elders were conducted with sociodemographic factors entered first, followed by stress factors, and then coping resources (Bass, Looman & Ehrlich 1992; Bumette & Mui 1994). The additive model (which is not presented in table form) explained 31% in the variance of psychological distress. Each set of predictors, except coping resource factors, made a significant incremental contribution to predicting psychological well-being of the total sample of Hispanic eiders. Thus, the first hypothesis was only partially supported because coping resources did not contribute significantly to the model. In addition to analyzing the additive effects of stress and coping factors on Hispanic psychological well-being, a second strategy was to analyze the interaction effects of nationality. Two dummy variables, Mexican American and Puerto Rican, were created in order to examine between group differences in the interactive model, with persons of Cuban ancestry serving as the reference group. The interaction model examined whether the effects of stress and coping differed among Hispanic nationality groups. This model (which is not presented in table form) was significant and explained 33% of the variance in psychological distress. The results show that four interaction terms (Puerto Rican by ADL; Puerto Rican by Fear of Dependence; Mexican by Perceived Health; and Mexican by Unmet Service Needs) were significant (19 < 0.05). The results indicate that the impact of these stress factors on psychological distress varied according to the nationality of the Hispanic elders. However, none of the interactions between coping resources and nationality was significant. Thus, the second hypothesis was also only partially supported. In order to examine specific correlates of psychological distress for each nationality group, parallel regression analyses were conducted separately for each group.
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Factors associated with psychological distress on three Hispanic elderly groups Table 3 presents the results of the hierarchical regression analyses for Mexican American, Cuban American, and Puerto Rican elders. Overall, factors associated with psychological distress of the three groups of Hispanic elders included being female, living alone, greater ADL impairment, poor perceived health, fewer doctor visits, fear of depending too much on others, having family conflicts, and more unmet service needs. None of the coping resources, in terms of formal and informal support, made any difference in predicting psychological distress. Neither the acculturation variable (English language proficiency) nor the number of children had any dependent effect on the psychological distress score. Specifically, the model for the Mexican American elders explained 31% (p < 0.0001) of the variance in psychological distress. For the Cuban American elders, the model explained 26% (p < 0.0001) of the variance in psychological distress. For Puerto Rican elders the model explained more variance (R 2 = 0.40; p < 0.0001) in psychological distress than for the other two groups. There were both differences and similarities in the correlates of distress for the three groups. Thus, the third hypothesis was also partially supported. The differences between the regression coefficients of the respective predictors were tested. All the respective slopes were different statistically at less than the 0.05 level. Results showed that ADL impairments, poor perceived health status, and unmet service needs were common correlates of psychological distress for all three groups. The magnitude of their effects, however, was different on the three groups as indicated by the respective regression coefficients. Compared to the other two groups, the effects of ADL impairment (b = 0.23) and poor perceived health (b = - 0 . 3 4 ) were the strongest on the Puerto Rican elders' psychological distress after controlling for other stress and coping factors in the model. Controlling for other factors, Mexican American and Puerto Rican older women reported a higher level of psychological distress, but gender differences were not found in the Cuban American elderly sample. The unique significant factor for Mexican American elders' psychological distress was fewer doctor visits. For Cuban American and Puerto Rican elders, fear of depending too much on others was a significant factor associated with their psychological distress, but the effect was stronger for the former group (b = 0.51 vs b = 0.42). Living alone was the only unique correlate for the Cuban American elders' psychological distress. In addition, family conflict was a common correlate for both Mexican American and Cuban American elders, but not
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Table 3. Correlates of psychological distress among three groups of Hispanic elders
Significant unstandardized regression coefficients (SE) Mexican American Cuban American Puerto Rican Sociodemographics
Age Gender (male = 1) Education Living arrangements (alone = l) Length of stay in USA On public assistance R 2 at this step
-0.38 (0.15)**
-0.39 (0.15)**
0.27 (0.12) **
0.03
0.04
0.03
Health-related stresses
0.12 (0.04)** ADL impairment -0.22 (0.09)** Self-perceived health -0.03 (0.01)** Doctor visits Hospital use Incremental to R 2 at this step O.12
0.07 (0.03)* -0.26 (0.06) . . . .
0.23 (0.05) . . . . -0.34 (0.09)***
0.12
0.27
0.51 (0.12) . . . .
0.42 (0.19)**
Personal and family stresses
Fear of dependence Caregiving duty Family conflicts Financial strain Unmet service needs Incremental to R2 at this step
0.55 (0.12)**
0.35 (0.13)**
0.14 (0.02) . . . .
0.08 (0.02) . . . .
o. 12 (0.03) . . . .
0.13
0.10
0.09
0.03
0.00
0.01
0.31
0.26
0.40
Coping resources
English ability Number of children Children contacts Friend contacts Church contacts In-home service use Community-based service Incremental to R2 at this step Total R2
*p < 0.05; ***p < 0.001; . . . . p < 0.0001.
for P u e r t o R i c a n elders. D a t a s h o w that f a m i l y conflicts h a d a m u c h g r e a t e r i m p a c t o n M e x i c a n A m e r i c a n e l d e r s ' p s y c h o l o g i c a l distress (b = 0 . 5 5 ) t h a n o n C u b a n A m e r i c a n elders (b = 0.35).
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Discussion
Using a national probability sample of Hispanic elderly persons, this study extends current knowledge about the roles of health-related and family stresses and coping resources in understanding psychological distress among Mexican Americans, Cuban Americans, and Puerto Ricans. The three hypotheses of this study were partially supported. A majority of health-related and personal and family stresses had a significant effect on the psychological distress of the three groups of Hispanic elders. Coping resources, however, did not predict psychological distress of any group. There are limitations to this study. First, interpretation of the results is limited by the cross-sectional nature of the study. Longitudinal studies are needed to determine the direction of the relationships among variables and the nature of changes in well-being over time. Second, because the researcher used secondary data, it was not possible to consider the effects of qualitative variables (such as perceived adequacy of formal and informal support) that were not measured in the original study. Other possible limitations to this study center on measurement issues. None of the coping resource variables were significant in explaining the psychological distress measure. These coping resource variables were measured only quantitatively, which may account for their lack of effect on the well-being measure. The quantitative measures did not provide information concerning the elders' subjective evaluation of the quality of these coping resources (Mui 1992). Data confirmed that elderly Mexican Americans, Cuban Americans, and Puerto Ricans indeed differed in levels of acculturation, as indicated by English language proficiency, length of stay in the USA, socioeconomic status, and availability of family support. With regard to the correlates of psychological distress, findings revealed more similarities than differences among the three groups. Their feeling of psychological distress was influenced by their functional impairments, poor perceived health status, and unmet needs in formal services. The association between these health-related stress factors and psychological distress is consistent with previous findings in the literature (Burnette & Mui 1994). The relationship of psychological distress to health status is complex, with psychological distress a natural response to health problems (Mui 1993). Literature also suggests that Hispanics tend to express psychological discomfort through somatic complaints (Garcia-Preto 1982). Furthermore, previous research suggests that lack of adequate access to health care services is associated with psychological distress (Parra & Espino 1992). In order to cope with their functional impairments and poor health status, Hispanic elders may have to deal with a bureaucratic health care system replete with problems such as poor access, language barriers, lack of private
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or government health insurance, and limited financial resources. In addition, due to the high cost of deductibles for hospital admission, copayments for outpatient visits, prescription medications, dental care, hearing aids, and eyeglasses, Hispanic elders may find the experience of seeking health care to be psychologically distressing and frustrating. Service providers may help lessen the psychological distress of Hispanic elders by advocating for federal and state programs that provide comprehensive health benefits for the elderly. Another important finding of the present study was the association between psychological distress and Hispanic elders' perceived unmet service needs. This finding is consistent with research on other ethnic elderly groups (Mui 1993), and may reflect service utilization problems among Hispanic elderly people such as accessibility, availability, affordability, and cultural acceptability. This finding highlights the need to re-evaluate existing service delivery systems so as to improve access for Hispanic elders and for other ethnic older people. Compared to the other two groups, data showed that Cuban American elders were more educated, less impaired functionally, had higher incomes, and better health status. These findings are consistent with the literature (Angel & Angel 1992; Bernal 1982). Although elderly Cuban Americans were less acculturated (indicated by their shorter length of stay in the USA and lower English language proficiency), they had lower levels of psychological distress. Unlike Mexican American and Puerto Rican elders, Cuban Americans who migrated to the USA were the upper and middle classes of society and generally did not return to Cuba because of that country's adverse political conditions. This lack of return migration may be one reason why Cuban elderly constitute a higher proportion of their Hispanic subgroup than do Puerto Ricans (Aguirre & Bigelow 1983). The stability of this migration pattern can explain why Cuban American elders benefit from close-knit ethnic enclaves that largely preserve their original culture and native language (Angel & Angel 1992; Perez 1986). The factor illustrates the importance of examining subgroup differences because of differences in the social and economic contexts of varied immigration experiences. With regard to the well-being of the Cuban American elders, living alone was a predictor of their feeling of psychological distress, which is consistent with research on other ethnic groups (Burnette & Mui 1994; Mui 1993). Living alone may indicate social isolation, dysfunctional family relationships, or breakdowns of family support all factors that increase the risk of psychological distress. Living alone may be particularly difficult for Cuban American elders, accustomed to affluence, financial and social resources, and family unity and loyalty much more than other Hispanic elders (Angel & Angel 1992).
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Older Mexican American and Puerto Rican women reported more psychological distress than did their male counterparts. It is well documented that older women across cultural and ethnic groups tend to report higher levels of psychological distress than do older men (Bumette & Mui 1994; Mui 1992, 1993). It may be culturally more acceptable and expected for women to express their feelings and emotions. Therefore, gender difference may be an artifact of older men's underreporting (Mui 1993). It is unclear why older Cuban women and older Cuban men did not differ. Elderly Cuban American men and women may be less willing to reveal their feelings and try to maintain their sense of pride about themselves and their culture (Bemal 1982). The present study also revealed that personal and family-related stress factors were important in understanding the psychological distress of these elderly groups. For Mexican American and Cuban American elders, family conflict was the common correlate for their psychological distress. For Cuban American and Puerto Rican elders, fear of depending too much on other people was a common predictor of distress. Elderly Mexican Americans and Cuban Americans rely mostly on their children and immediate family members for support (Lacayo 1980; Markides & Krause 1985); therefore family conflicts and problems may indicate that the expected family support is not available. Because family is the most important unit in the life of these elders, relationship problems and conflicts within the family may be difficult to bear. Family counseling may enable these elders and their families to resolve family conflicts which may stem from intergenerational differences in acculturation and beliefs in family unity. The association between psychological distress and personal and familyrelated stress was an important finding which suggests that ethnic family experience is not always positive and problem free. Because family bonding and reciprocity between generations is expected within the Hispanic culture (Markides & Krause 1985, 1986), it makes sense that family conflicts play an important role in explaining well-being. However, it is unclear why family conflict did not predict psychological distress among Puerto Rican elders. It has been suggested that Puerto Rican elders were more spiritual and accepting or tolerant of stress and problems (Garcia-Preto 1982). Furthermore, for Cuban American and Puerto Rican elders, concern about having to depend too much on other people may reflect two factors: worry about the availability of support when needed, and the tendency for these elders to seek only the help of children but not other relatives (Escovar & Kurtines 1983). On the other hand, it is difficult to tell whether concern about dependency was due to deterioration of familism or weakening of elder care values in the family. Because this is a cross-sectional study, it is difficult to draw conclusions regarding causality.
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These findings suggest several directions for improving the overall wellbeing of Hispanic elders. Practitioners need to be trained to understand the health-related, personal, and family stresses that are associated with the psychological distress of these elders. For service providers, it is important to recognize that the emotional well-being of Hispanic elders is closely tied to their functional impairment, health status, unmet service needs, gender, living arrangements, fear of dependence, and family conflicts. Consideration of these variables is essential to the design of culturally appropriate services for these three groups of Hispanic elders. The findings of the present study highlight the vulnerability of the three groups of Hispanic elders who are at risk of psychological distress. Further research should focus on understanding what kind of coping and social support factors could help to alleviate their psychological distress. The findings also point to the importance of considering national origin when serving and studying Hispanic elders.
Acknowledgments The author would like to thank the Inter-University Consortium for Political and Social Research for making the data available. The data for the national Survey of Hispanic Elderly People were originally collected by Karen Davis and the Commonwealth Fund. Neither the collector nor the Consortium can bear any responsibility for the analyses or interpretations presented in this paper.
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Bernal G. (1982). Cuban families. In M. McGoldrick, J.K. Pearce & J. Giordano (eds.), Ethnicity and family therapy (pp. 187-207). New York: The Guilford Press. Biafora F.A. & Longino C.E (1990). Elderly Hispanic migration in the United States, Journal of Gerontology 45: $212-219. Bradburn N.M. (1969). The structure of psychological well-being. Chicago: Aldine. Burnette D. & Mui A.C. (1994). Determinants of self-reported depressive symptoms by frail elderly persons living alone, Journal of Gerontological Social Work 22: 3-19. Burnette D. & Mui A.C. (1995). In-home and community-based service use by three groups of elderly Hispanics: A national perspective, Social Work Research 19: 197-206. Cantor M.H. (1979). The informal support system of New York's inner city elderly: Is ethnicity a factor? In D.E. Gelfand & A. Kutzik (eds.), Ethnicity and aging: Theory, research, and policy (pp. 153-174). New York: Springer Verlag. Commonwealth Fund Commission on Elderly People Living Alone (1989) Poverty and poor health among elderly Hispanic Americans. Davis K. (1990). National survey of Hispanic elderly people, 1988. Ann Arbor, MI: InterUniversity Consortium for Political and Social Research. Escovar L.A. & Kurtines W.M. (1983). Psychological predictors of service utilization among Cuban American elders, Journal of Community Psychology 11: 355-362. Garcia-Preto N. (1982). Puerto Rican families. In M. McGoldrick, J.K. Peace & J. Giordano (eds.), Ethnicity and family therapy (pp. 164--186). New York: The Guilford Press. Gelfand D. & Yee B.W.K. (1991). Influence of immigration, migration, and acculturation on the fabric of aging in America, Generations 15: 7-10. Greene V.L. & Monahan D.J. (1984). Comparative utilization of community-based long term care service by Hispanic and Anglo elderly in a case management system, Journal of Gerontology 39: 730-735. Husaini B.A., Moore S.T., Castor W.N., Whitten-Stovall R., Linn G. & Griggin D. (1991). Social density, stressors, and depression: Gender differences among the black elderly, Journal of Gerontology 46: P236-242. Kemp B.J., Staples E & Lopez-Aqueres W. (1987). Epidemiology of depression and dysphoria in an elderly Hispanic population: Prevalence and correlates, Journal of American Geriatric Society 35: 920-926. Kessler R.C. & Neighbors H.W. (1986). A new perspective on the relationships among race, social class, and psychological distress, Journal of Health and Social Behavior 27: 107115. Krause N. & Goldenhar L.M. (1992). Acculturation and psychological distress in three groups of elderly Hispanics, Journal of Gerontology 47: $279-$288. Kulys R. (1990). The ethnic factor in the delivery of social services. In A. Monk (ed.), Handbook of gerontological services, 2rid ed. (pp. 629-661). New York: Columbia University Press. Lacayo C.G. (1980). A national study to assess the service needs of the Hispanic elderly. Washington, DC: Library of Congress. Lacayo C.G. & Crawford J.K. (1980). A national study to assess the service needs of the Hispanic elderly. Los Angeles, CA: Association National Pro Personas Mayores. Lazarus R.S. & Folkman S. (1984). Stress, appraisal, and coping. New York: Springer Verlag. Linn M.W., Hunter K.I. & Perry P.R. (1979) Differences by sex and ethnicity in the psychosocial adjustment of the elderly, Journal of Health and Social Behavior 20: 273-281. Lubben J.E. & Becerra R.M. (1987). Social support among black, Mexican and Chinese elderly. In D.E. Gelfand & C.M. Barresi (eds.) Ethnic dimension of aging (pp. 130-144). New York: Springer Verlag. Mahard R.E. (1988). The CES-D as a measure of depressive mood in elderly Puerto Rican population, Journal of Gerontology 43: P24-25. Markides K.S. & Krause N. (1985). Intergenerational solidarity and psychological well-being among older Mexican-American: A three generations study, Journal of Gerontology 40: 390-392.
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Markides K.S. & Krause N. (1986). Older Mexican Americans: Family relationships and well-being, Generations 10:31-34. Markides K.S. & Mindel C. (1987). Aging and ethnicity. Beverly Hills, CA: Sage Publications. Marks G., Solis J., Richardson J.L., Collins L.M., Birba L. & Hisserich J.C. (1987). Health behavior of elderly Hispanic women: Does cultural assimilation make a difference?, American Journal of Public Health 77: 1315-1319. Mui A.C. (1992). Caregiver strain among black and white daughters caregivers: A role theory perspective, The Gerontologist 32: 203-212. Mui A.C. (1993). Self-reported depressive symptoms among black and Hispanic elders: A sociocultural perspective, Journal of Applied Gerontology 12:170-187. Mui A.C. & Burnette D. (1994). Long-term care service use by frail elders: Is ethnicity a factor?, The Gerontologist 34:90-198. Norris EH. & Murrell S.A. (1984). Protective function of resources related to life events, global stress, and depression in older adults, Journal of Health and social behavior 25: 424--437. Parra E.O. & Espino D.V. (1992). Barriers to health care access faced by elderly Mexican Americans. In T.L. Brink (ed.), Hispanic aged mental health (pp. 171-177). New York: The Haworth Press. Perez L. (1986). Cubans in the United States, Annals of the American Academy of Political and Social Science 487: 126-137. Rook K.S. (1984). The negative side of social interaction: Impact on psychological well-being, Journal of Personality and Social Psychology 46:1097-1108. Starrett R.A., Todd A.M. & De Leon L. (1989). A comparison of social service utilization behavior of the Cuban and Puerto Rican elderly, Hispanic Journal of Behavioral Sciences 11: 341-353. Starrett R.A., Wright R., Mindel C.H. & Tran T.V. (1989). The use of social services by Hispanic elderly: A comparison of Mexican American, Puerto Rican, and Cuban elderly, Journal of Social Service Research 13: 1-25. US Bureau of the Census (1990). Population estimates by age, sex, race and Hispanic origin: 1989. Washington, DC, Current Population Reports, Series P-25, No. 1057. US Senate Special Committee on Aging, American Association of Retired Persons, Federal Council on the Aging, and US Administration on Aging (1991). Aging American: Trends and projections. Washington, DC: US Department of Health and Human Services, Pub. No. (FCoA) 91-28001. Vaux A. (1985). Variations in social support associated with gender, ethnicity, and age, Journal of Social Issues 41:89-110. Westat, Inc. (1989). A survey of elderly Hispanics. Report of the Commonwealth Fund Commission on Elderly People Living Alone.
Address for correspondence: Ada C. Mui, PhD, ACSW, Columbia University, School of Social Work, 622 W. 113th Street, New York, NY 10025, USA Phone: (212)854 7394; Fax: (212) 854 2975; E-mail: [email protected]
Correlates of psychological distress among Mexican, Cuban, and Puerto Rican elders living in the USA A D A C. M U I Columbia University, New York, USA
Abstract. Little is known about the impact of coping resources and health-related and family stresses on the well-being of Hispanic elders, or the extent to which these factors operate differentially for various Hispanic nationality groups. The present study examined the correlates of psychological distress of three groups of Hispanic elders. The researcher analyzed the Mexican American (n = 773) Cuban American (n = 714), and Puerto Rican (n = 368) elderly individuals drawn from the 1988 National Survey of Hispanic Elderly People in the USA. Multivariate analyses results indicated that activities of daily living impairments, poor perceived health, and unmet needs in formal social service were common predictors of psychological distress for all three groups. Older Mexican American women and Puerto Rican women reported higher levels of psychological distress than their male counterparts, other things being equal. For Cuban American elders, fear of depending too much on others, conflicts in the family, and living alone were unique predictors of their psychological distress. Key words: Stress, Coping, Psychological well-being, Mexican Americans, Cuban Americans, Puerto Rican Americans, USA
Introduction Hispanic elders in the USA are not a homogeneous group. They differ by country, region o f origin, cultural background, degree o f acculturation, socioeconomic class, education level, migration history, and political ideology. Research has usually ignored the ethnic variation among the Hispanic elderly population and has lumped them together as if they are a homogeneous group (Mui 1993; Mui & Bumette 1994). At present, about 5% o f all persons aged 65 and over are Hispanic, and this group is one o f the fastest growing populations nationwide (US Bureau o f Census 1990). It is estimated that while the older white population is expected to grow by 92% between 1990 and 2030, the projected increase for older Hispanics is 395% (US Senate Special Committee on Aging 1991). Some gerontologists suggest that the stresses o f immigration, acculturation, poverty, illnesses, functional impairments, and weakening family support may be sources o f their poor health and psychological distress (Gelfand & Yee 1991; Mahard 1988).
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This study used data from the 1988 National Survey of Hispanic Elderly People to examine the correlates of psychological well-being among older Mexican Americans, Cuban Americans, and Puerto Ricans. The first objective of this study was to determine the roles that health-related and family stresses and coping resources play in predicting well-being. A second objective was to determine if these relationships differed among Hispanic nationality groups.
Literature review
Recent research has begun to document the serious financial, health, and psychological problems that Hispanic elders face in the USA (e.g., Andrews, Lyons & Rowland 1992; Angel & Angel 1992; Bastida 1984; Krause & Goldenhar 1992). These studies confirm that Hispanic elders experience both the absolute and relative disadvantages suffered by most older ethnic minority groups. For example, in comparing a national random sample of all older Americans (Commonwealth Fund 1989) with Hispanic elderly persons in a companion data set (Westat 1989), Andrews, Lyons & Rowland (1992) found that Hispanic elders fared worse on almost all major dimensions of health and well-being, particularly on measures of income, command of English, educational attainment, and functional status. Research evidence also indicates that racial and ethnic minorities experience more psychological distress than majority Americans (Kemp, Staples & Lopez-Aqueres 1987; Kessler & Neighbors 1986). Ethnic minority status is associated with low income, minimal education, substandard housing, and lack of opportunity (Markides & Mindel 1987). Ethnic minority elders living under these conditions not only experience more strain and stress but often have fewer social and psychological coping resources (Kulys 1990). Some researchers have examined the role of cultural assimilation in understanding the health behavior of these elders (Marks, Solis, Richardson, Collins, Birba & Hisserich 1987). Findings showed that after controlling for education and age, no dimension of assimilation was associated with health behavior. These findings suggest that factors other than assimilation, such as access to and availability of services, the adequacy of informal support, and sociodemographic characteristics may be stronger determinants of Hispanic health practices. Researchers have also studied the role of informal support systems, particularly family members, and their impact on the mental and physical wellbeing of ethnic elders (Cantor 1979, Lubben & Becerra 1987). Findings are mixed. Several studies found that social support systems can mediate the impact of stress among the elderly (Arling 1987; Husaini, Moore, Castor, Whitten-Stovall, Linn & Griggin 1991; Noms & Murrell 1984). However,
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other evidence indicated that family support can be a source of psychological distress among the elderly (e.g., Rook 1984). For example, some research on Hispanic elders indicated that health problems and increased family support were associated with depression (Kemp et al. 1987; Mahard 1988). Markides & Krause (1985) found that high levels of family interaction were associated with greater depression among older Mexicans. By and large, studies on Hispanic family support have shown consistently that Hispanic elders have stronger bonds with family members and higher levels of interaction and support from children, than either black or white elders, controlling for gender and social class (Cantor 1979; Lubben & Becerra 1987). Furthermore, there is a strong sense of family obligation that often supersedes the needs of individual family members. Hispanic elders also expect their family to assist them in their old age and treat them with respect (Markides & Krause 1985). These studies suggest that there is an ethnic factor in family social support. Some differences in family support and services use among ethnic groups can be attributed to culture, socioeconomic status, and immigration patterns (Linn, Hunter & Perry 1979; Markides & Mindel 1987). Family supports and formal services use also may vary greatly according to the degree of acculturation (Vaux 1985). This may be especially true among Hispanic elders, over 50% of whom came from abroad (Biafora & Longino 1990). Some evidence has suggested that there are differences in family support among Hispanic subgroups. Older Cuban Americans generally have sought only the help of their children and not that of other family members (Escovar & Kurtines 1983). Among Mexican Americans, there has been a high level of exchange and reciprocity between generations of children and grandchildren (Markides & Krause 1986). Puerto Rican elders, unlike Mexican Americans, Cuban Americans, and other Hispanics, have relied on themselves and friends for assistance more than on family members (Lacayo & Crawford 1980). Association between family members and Hispanic elders may not always be beneficial for elders. As stated above, research has indicated that increased association of older Mexican Americans with their children was related to an increase in the elders' depression (Markides & Krause 1985, 1986). These data suggest that family contact can become a source of stress. In this study, the impact of health-related and family stresses on the psychological wellbeing among the three groups of Hispanic elders was examined. Most researchers have ignored the diverse cultural, historical, demographic and ecological conditions of Hispanic subnational groups in the USA (Aguirre & Bigelow 1983), merging Mexican Americans, Cuban Americans, and Puerto Ricans into one 'Hispanic' category. Recent large national studies of Hispanic elders that used inferential statistical models to examine dif-
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ferences among and within Hispanic subgroups revealed substantial group variations. Group variations were also associated with differential patterns of family dynamics, service need, and preference for formal service use (Starrett, Todd & De Leon 1989; Starrett, Wright, Mindel & Tran 1989). In this study, a stress and coping framework (Aldwin 1994; Lazarus & Folkman 1984) was used to conceptualize and examine the relation between stresses, coping resources and psychological well-being outcome for Hispanic elders. The stress and coping framework acknowledges the importance of personal and environmental stress, such as family conflicts, and their effects on elders' overall well-being (Aldwin 1994; Mui 1993). Methods for coping with stress are determined by cognitive appraisal and include both cognitive and behavioral efforts to manage stresses that are appraised as taxing. Coping resources usually include physical, psychological, spiritual, social skills, and social supports that are available to an individual (Burnette & Mui 1994; Lazarus & Folkman 1984; Mui 1993). Theoretically, there are at least two possible ways in which coping can affect well-being outcomes. First, there may be direct effects on well-being measures. Second, the coping strategies may moderate or buffer the effect of stress on well-being outcomes (Aldwin 1994). In this study, both additive and interactive effects of stress and coping resources were tested with the whole Hispanic elderly sample. In addition, the author also tested group differences among Hispanic nationality groups in the stress and coping process. Therefore, three hypotheses were tested: H1 Stress factors and coping resources have significant additive effects on the psychological well-being of Hispanic elders. H2 Stress and coping resource factors have interactive effects with nationality groups on the level of psychological well-being. H3 Correlates of psychological well-being are different for the three groups of Hispanic elders.
Methods
Sample and data sources
Data are from the 1988 National Survey of Hispanic Elderly People. The study, a part of the Commonwealth Fund Commission's project on elderly people living alone (Commonwealth Fund 1989), used a telephone survey to obtain a profile of the health, economic, and social circumstances of Hispanic people aged 65 and over. Between August and October 1988, trained, bilingual interviewers gathered information on living arrangements, length of time living in the USA, economic resources, health and functional status, social network, family support, and psychological well-being (Davis 1990).
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The survey provides a nationally representative sample of Hispanics age 65 and over, living within telephone exchanges with at least 30% concentrations of Hispanic residents in three geographic areas in the continental USA. Using random digit dialing, 48,183 households were screened for Hispanics aged 65 and over, resulting in completed interviews of 2,299 older Hispanics. The overall response rate was 80%. Eighty-seven percent of interviewees chose to be interviewed in Spanish. The analyses presented in this paper are based on a subsample (unweighted numbers) of Mexican Americans (n = 773), Cuban Americans (n = 714) and Puerto Ricans (n = 368). Other Hispanic groups were not included because their numbers were limited. Almost all the Cuban American (99%) and Puerto Rican elders (98%), but only 42% of the Mexican American elders were foreign born. Measures Outcome variables. Psychological distress was assessed by self-reported experiences in the last few weeks of feeling restless, remote from other people, bored, depressed, upset, lonely, and anxious (each coded dichotomously). A principal components analysis with varimax rotation was performed and a one-factor solution was identified. The seven items were summed to create a composite score of psychological distress (Cronbach alpha = 0.76). The first five items are comparable to the negative affect items in the Affective-Balance Scale (Bradbum 1969). Independent variables. Based on the literature review and stress and coping framework, the independent variables were conceptualized and categorized into sociodemographic, health-related, personal and family stresses, and coping resources factors. With regard to sociodemographic variables, receipt of public assistance was treated as a proxy measure of income because the income variable was not usable due to excessive missing data. Age, sex, education, living arrangements, and length of stay in USA (as an indicator of acculturation) were included as controls so that the effects on stress and coping resources factors could be assessed. Two dummy variables, Mexican American and Puerto Rican, were created in order to examine between group differences in the interactive model, with persons of Cuban ancestry serving as the reference group, which is consistent with the literature (Bumette & Mui 1995; Krause & Goldenhar 1992). Health-related, personal, and family stress factors included Activity of Daily Living (ADL) impairment, perceived health, number of doctor visits, hospital use, fear of dependence, caregiving duty, family conflicts, financial strain, and unmet needs in formal services. Previous research has shown that these three groups of Hispanic elders differ greatly in migration experience,
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lengths of stay in the USA, levels of acculturation, education, and socioeconomic status (e.g., Angel & Angel 1992, Bean & Tienda 19873. These group differences may translate into differential health status in late life which might be associated with their perceived psychological distress. For these Hispanic elders, the combined effects of language barriers, financial strain, aging, health deterioration, functional impairment, and adjustments to the demands of health care system, may prove particularly stressful. English language ability, number of children, frequency of contact with children, with friends, church, and utilization of in-home and communitybased services were conceptualized as coping resources available to these Hispanic elders. English language proficiency, which varies by level of education, age of immigration, and nationality was used as a proxy for acculturation (Angel & Angel 1992; Krause & Goldenhar 1992). Family, friends, and church support are significant emotional and instrumental resources. Despite disadvantages associated with low income, low educational attainment, English language deficits, and poorer health status, older Hispanics, like most other older ethnic elders, tend to underutilize formal services (Greene & Monahan 1984). Service use is a complex behavior associated with factors such as kin as well as service availability, accessibility, and cultural acceptability (Burnette & Mui 1995).
Results
Description of sample Descriptive statistics were used to generate a sociodemographic profile of the three groups of Hispanic elders. Table 1 presents a descriptive profile of the three groups of Hispanic elderly people. These data show that the Hispanic elderly population, as suggested above, is not a homogenous group. About one-fifth of the Mexican and Cuban Americans were aged 80 or older, making them somewhat older than the Puerto Ricans. Cuban American elders fared better than either of the other two groups. Puerto Rican eiders were more likely than the other two groups to fall below the poverty line (41.1%) and fewer Puerto Ricans had private insurance. In addition, nearly two-thirds of the Puerto Rican elders were unmarried (compared to fewer than half of the other groups), and nearly twice the percentage of this group lived alone. Cuban Americans had the least command of English language skills, indicating that they may be less assimilated. Furthermore, both Puerto Rican and Mexican American elders had completed fewer years of education than Cuban American elders. More than 80% of the Puerto Rican and Mexican American elders had not graduated from high school while 18% of the Cuban
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Table 1. Sociodemographic characteristics of three groups of Hispanic elders (in %) Mexican American (N = 773) ~
Age . . . . 65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 and over Mean Age Gender Female Marital status Married . . . . Education . . . . Grade school or less High school College or more Living arrangement . . . . Alone With others SSI Private insurance . . . . Self-rated English language skills Able to speak . . . . Able to read . . . . Able to write . . . . Length of stay in the US. . . . Household income . . . . $ 5,500 or less $ 5,501-15,000 $15,001 or more
37.7 23.0 18.6 13.7 7.0 73.1
Cuban American (N = 714) ~ Percentagesp 32.3 23.9 22.7 12.8 8.3 74.3
Puerto Rican (N = 368) ~
39.9 24.2 19.6 9.5 6.8 72.2
62.5
62.5
66.6
51.1
53.1
34.1
81.6 15.3 3.1
59.2 23.0 17.8
84.0 12.2 3.8
22.1 77.9 12.2 27.9
21.0 79.0 13.2 31.8
36.7 63.3 16.5 16.3
46.3 56.3 44.9 47.6
36.7 43.4 34.5 24.0
51.4 51.9 41.0 38.2
36.6 51.4 12.0
35.1 44.5 20.4
41.5 47.6 10.9
Note: Chi-square statistic was used. ~Unweighted numbers. VPercents based on unweighted numbers. . . . . p < 0.0001.
A m e r i c a n e l d e r s h a d a c o l l e g e l e v e l e d u c a t i o n . T h e first t w o g r o u p s a l s o h a d t w i c e as m a n y c h i l d r e n as did C u b a n A m e r i c a n elders, i n d i c a t i n g s u b s t a n t i a l l y h i g h e r fertility. T a b l e 2 p r e s e n t s th e m e a n s a n d s t a n d a r d d e v i a t i o n s o f all m a j o r v a r i a b l e s in t h e m u l t i p l e r e g r e s s i o n m o d e l s . T h e s e d a t a s h o w that C u b a n A m e r i c a n a n d M e x i c a n A m e r i c a n e l d e r s h a d less p s y c h o l o g i c a l d i s t r e s s than P u e r t o
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Table 2. Means and standard deviation of major variables Mexican American (N = 773)
Psychological distress items Restless**** Remote*** Bored**** Depressed* Upset* Lonely Anxiety*
Cuban American (N = 714)
Puerto Rican (N = 368)
Percentages 22.3 36.9 22.6 33.2 23.9 37.5 27.7 35.9 8.1 11.7 21.6 26.9 37.5 45.7 Means (standard deviation) 1.83 (1.91) a 1.64 (1.81) ~ 2.28 (2.15) b 23.7 25.2 26.8 29.1 11.8 23.8 42.2
Psychological distress (Composite score: 1-7) Health-related stresses ADL impairments (1-7) Self-perceived health (1-4) Doctor visits (per year) Hospital use (yes = 1) Personal and family stresses Fear of dependence (yes = 1) Caregiving duty (yes = 1) Family conflicts (yes = 1) Financial strain (yes = I) Unmet needs (0-9) Coping resources English ability (0-3) Number of children Children contacts (per week) Friend contacts (yes = 1) Church contacts (yes = 1) In-home service use (0-4) Community-based use (0-5)
1.41 2.42 6.39 0.21
(1.10) ~ (0.86) '~ (7.53) a (0.41) a
0.82 2.62 8.03 0.23
(1.00) b (0.86) b (9.99) b (0.42) a
1.39 2.31 11.65 0.30
(1.45) c (0.84) c (9.81) c (0.45) b
0.32 0.21 0.22 0.80 2.13
(0.46) a (0.40) a (0.41) a (0.80) ~ (2.14) a
0.26 0.16 0.17 0.52 1.35
(0.43) b (0.36) b (0.37) b (0.70) b (2.10) b
0.27 0.20 0.25 0.66 2.11
(0.44) b (0.40) ~ (0.43) c (0.75) c (2.10) a
1.47 4.64 2.51 0.61 0.40 0.28 0.49
(1.22) a (3.26) a (1.80) a (0.21) a (0.32) '~ (0.18) ~ (0.36) ~
1.15 2.05 1.58 0.46 0.49 0.23 0.43
(1.31) b (1.68) b (1.58) b (0.11) b (0.32) b (0.19) ~ (0.37) ~
1.44 3.81 1.31 0.47 0.37 0.44 0.68
(1.28) a (2.88) c (0.83) b (0.23) b (0.11) c (0.30) b (0.31) b
Note: Chi-square statistics were used to test the proportion differences. ANOVA statistics with post hoc multiple comparisons were used to test the differences among means. Means with the different letters are significantly different at less than the 0.05 level in the same variable. *p < 0.05; ***p < 0.001; . . . . p < 0.0001.
Rican elders. Among the health-related and family stress factors, Cuban American elders had better self-perceived health and less financial strain than their Mexican
American
and Puerto Rican counterparts.
Cuban
American
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elders were also least impaired in ADL. They also reported fewer unmet service needs, caregiving responsibilities, and family conflicts. In terms of coping resources, including the two types of formal service use (in-home and community-based) and informal network variables for the three subgroups, Puerto Rican eiders reported a much higher use of in-home and communitybased services than the other two groups. Mexican American elders reported having more living children and more frequent contact with children each week.
Multivariate analyses Hierarchical regression analyses were conducted to test the three hypotheses. For the first two hypotheses, a simple additive model and a model with additive and interactive effects were used to test the differential impacts of stress and coping factors on psychological well-being of Hispanic elders. For the third hypothesis, three separate hierarchical regressions for the three groups of Hispanic elders were conducted with sociodemographic factors entered first, followed by stress factors, and then coping resources (Bass, Looman & Ehrlich 1992; Bumette & Mui 1994). The additive model (which is not presented in table form) explained 31% in the variance of psychological distress. Each set of predictors, except coping resource factors, made a significant incremental contribution to predicting psychological well-being of the total sample of Hispanic eiders. Thus, the first hypothesis was only partially supported because coping resources did not contribute significantly to the model. In addition to analyzing the additive effects of stress and coping factors on Hispanic psychological well-being, a second strategy was to analyze the interaction effects of nationality. Two dummy variables, Mexican American and Puerto Rican, were created in order to examine between group differences in the interactive model, with persons of Cuban ancestry serving as the reference group. The interaction model examined whether the effects of stress and coping differed among Hispanic nationality groups. This model (which is not presented in table form) was significant and explained 33% of the variance in psychological distress. The results show that four interaction terms (Puerto Rican by ADL; Puerto Rican by Fear of Dependence; Mexican by Perceived Health; and Mexican by Unmet Service Needs) were significant (19 < 0.05). The results indicate that the impact of these stress factors on psychological distress varied according to the nationality of the Hispanic elders. However, none of the interactions between coping resources and nationality was significant. Thus, the second hypothesis was also only partially supported. In order to examine specific correlates of psychological distress for each nationality group, parallel regression analyses were conducted separately for each group.
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Factors associated with psychological distress on three Hispanic elderly groups Table 3 presents the results of the hierarchical regression analyses for Mexican American, Cuban American, and Puerto Rican elders. Overall, factors associated with psychological distress of the three groups of Hispanic elders included being female, living alone, greater ADL impairment, poor perceived health, fewer doctor visits, fear of depending too much on others, having family conflicts, and more unmet service needs. None of the coping resources, in terms of formal and informal support, made any difference in predicting psychological distress. Neither the acculturation variable (English language proficiency) nor the number of children had any dependent effect on the psychological distress score. Specifically, the model for the Mexican American elders explained 31% (p < 0.0001) of the variance in psychological distress. For the Cuban American elders, the model explained 26% (p < 0.0001) of the variance in psychological distress. For Puerto Rican elders the model explained more variance (R 2 = 0.40; p < 0.0001) in psychological distress than for the other two groups. There were both differences and similarities in the correlates of distress for the three groups. Thus, the third hypothesis was also partially supported. The differences between the regression coefficients of the respective predictors were tested. All the respective slopes were different statistically at less than the 0.05 level. Results showed that ADL impairments, poor perceived health status, and unmet service needs were common correlates of psychological distress for all three groups. The magnitude of their effects, however, was different on the three groups as indicated by the respective regression coefficients. Compared to the other two groups, the effects of ADL impairment (b = 0.23) and poor perceived health (b = - 0 . 3 4 ) were the strongest on the Puerto Rican elders' psychological distress after controlling for other stress and coping factors in the model. Controlling for other factors, Mexican American and Puerto Rican older women reported a higher level of psychological distress, but gender differences were not found in the Cuban American elderly sample. The unique significant factor for Mexican American elders' psychological distress was fewer doctor visits. For Cuban American and Puerto Rican elders, fear of depending too much on others was a significant factor associated with their psychological distress, but the effect was stronger for the former group (b = 0.51 vs b = 0.42). Living alone was the only unique correlate for the Cuban American elders' psychological distress. In addition, family conflict was a common correlate for both Mexican American and Cuban American elders, but not
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Table 3. Correlates of psychological distress among three groups of Hispanic elders
Significant unstandardized regression coefficients (SE) Mexican American Cuban American Puerto Rican Sociodemographics
Age Gender (male = 1) Education Living arrangements (alone = l) Length of stay in USA On public assistance R 2 at this step
-0.38 (0.15)**
-0.39 (0.15)**
0.27 (0.12) **
0.03
0.04
0.03
Health-related stresses
0.12 (0.04)** ADL impairment -0.22 (0.09)** Self-perceived health -0.03 (0.01)** Doctor visits Hospital use Incremental to R 2 at this step O.12
0.07 (0.03)* -0.26 (0.06) . . . .
0.23 (0.05) . . . . -0.34 (0.09)***
0.12
0.27
0.51 (0.12) . . . .
0.42 (0.19)**
Personal and family stresses
Fear of dependence Caregiving duty Family conflicts Financial strain Unmet service needs Incremental to R2 at this step
0.55 (0.12)**
0.35 (0.13)**
0.14 (0.02) . . . .
0.08 (0.02) . . . .
o. 12 (0.03) . . . .
0.13
0.10
0.09
0.03
0.00
0.01
0.31
0.26
0.40
Coping resources
English ability Number of children Children contacts Friend contacts Church contacts In-home service use Community-based service Incremental to R2 at this step Total R2
*p < 0.05; ***p < 0.001; . . . . p < 0.0001.
for P u e r t o R i c a n elders. D a t a s h o w that f a m i l y conflicts h a d a m u c h g r e a t e r i m p a c t o n M e x i c a n A m e r i c a n e l d e r s ' p s y c h o l o g i c a l distress (b = 0 . 5 5 ) t h a n o n C u b a n A m e r i c a n elders (b = 0.35).
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Discussion
Using a national probability sample of Hispanic elderly persons, this study extends current knowledge about the roles of health-related and family stresses and coping resources in understanding psychological distress among Mexican Americans, Cuban Americans, and Puerto Ricans. The three hypotheses of this study were partially supported. A majority of health-related and personal and family stresses had a significant effect on the psychological distress of the three groups of Hispanic elders. Coping resources, however, did not predict psychological distress of any group. There are limitations to this study. First, interpretation of the results is limited by the cross-sectional nature of the study. Longitudinal studies are needed to determine the direction of the relationships among variables and the nature of changes in well-being over time. Second, because the researcher used secondary data, it was not possible to consider the effects of qualitative variables (such as perceived adequacy of formal and informal support) that were not measured in the original study. Other possible limitations to this study center on measurement issues. None of the coping resource variables were significant in explaining the psychological distress measure. These coping resource variables were measured only quantitatively, which may account for their lack of effect on the well-being measure. The quantitative measures did not provide information concerning the elders' subjective evaluation of the quality of these coping resources (Mui 1992). Data confirmed that elderly Mexican Americans, Cuban Americans, and Puerto Ricans indeed differed in levels of acculturation, as indicated by English language proficiency, length of stay in the USA, socioeconomic status, and availability of family support. With regard to the correlates of psychological distress, findings revealed more similarities than differences among the three groups. Their feeling of psychological distress was influenced by their functional impairments, poor perceived health status, and unmet needs in formal services. The association between these health-related stress factors and psychological distress is consistent with previous findings in the literature (Burnette & Mui 1994). The relationship of psychological distress to health status is complex, with psychological distress a natural response to health problems (Mui 1993). Literature also suggests that Hispanics tend to express psychological discomfort through somatic complaints (Garcia-Preto 1982). Furthermore, previous research suggests that lack of adequate access to health care services is associated with psychological distress (Parra & Espino 1992). In order to cope with their functional impairments and poor health status, Hispanic elders may have to deal with a bureaucratic health care system replete with problems such as poor access, language barriers, lack of private
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or government health insurance, and limited financial resources. In addition, due to the high cost of deductibles for hospital admission, copayments for outpatient visits, prescription medications, dental care, hearing aids, and eyeglasses, Hispanic elders may find the experience of seeking health care to be psychologically distressing and frustrating. Service providers may help lessen the psychological distress of Hispanic elders by advocating for federal and state programs that provide comprehensive health benefits for the elderly. Another important finding of the present study was the association between psychological distress and Hispanic elders' perceived unmet service needs. This finding is consistent with research on other ethnic elderly groups (Mui 1993), and may reflect service utilization problems among Hispanic elderly people such as accessibility, availability, affordability, and cultural acceptability. This finding highlights the need to re-evaluate existing service delivery systems so as to improve access for Hispanic elders and for other ethnic older people. Compared to the other two groups, data showed that Cuban American elders were more educated, less impaired functionally, had higher incomes, and better health status. These findings are consistent with the literature (Angel & Angel 1992; Bernal 1982). Although elderly Cuban Americans were less acculturated (indicated by their shorter length of stay in the USA and lower English language proficiency), they had lower levels of psychological distress. Unlike Mexican American and Puerto Rican elders, Cuban Americans who migrated to the USA were the upper and middle classes of society and generally did not return to Cuba because of that country's adverse political conditions. This lack of return migration may be one reason why Cuban elderly constitute a higher proportion of their Hispanic subgroup than do Puerto Ricans (Aguirre & Bigelow 1983). The stability of this migration pattern can explain why Cuban American elders benefit from close-knit ethnic enclaves that largely preserve their original culture and native language (Angel & Angel 1992; Perez 1986). The factor illustrates the importance of examining subgroup differences because of differences in the social and economic contexts of varied immigration experiences. With regard to the well-being of the Cuban American elders, living alone was a predictor of their feeling of psychological distress, which is consistent with research on other ethnic groups (Burnette & Mui 1994; Mui 1993). Living alone may indicate social isolation, dysfunctional family relationships, or breakdowns of family support all factors that increase the risk of psychological distress. Living alone may be particularly difficult for Cuban American elders, accustomed to affluence, financial and social resources, and family unity and loyalty much more than other Hispanic elders (Angel & Angel 1992).
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Older Mexican American and Puerto Rican women reported more psychological distress than did their male counterparts. It is well documented that older women across cultural and ethnic groups tend to report higher levels of psychological distress than do older men (Bumette & Mui 1994; Mui 1992, 1993). It may be culturally more acceptable and expected for women to express their feelings and emotions. Therefore, gender difference may be an artifact of older men's underreporting (Mui 1993). It is unclear why older Cuban women and older Cuban men did not differ. Elderly Cuban American men and women may be less willing to reveal their feelings and try to maintain their sense of pride about themselves and their culture (Bemal 1982). The present study also revealed that personal and family-related stress factors were important in understanding the psychological distress of these elderly groups. For Mexican American and Cuban American elders, family conflict was the common correlate for their psychological distress. For Cuban American and Puerto Rican elders, fear of depending too much on other people was a common predictor of distress. Elderly Mexican Americans and Cuban Americans rely mostly on their children and immediate family members for support (Lacayo 1980; Markides & Krause 1985); therefore family conflicts and problems may indicate that the expected family support is not available. Because family is the most important unit in the life of these elders, relationship problems and conflicts within the family may be difficult to bear. Family counseling may enable these elders and their families to resolve family conflicts which may stem from intergenerational differences in acculturation and beliefs in family unity. The association between psychological distress and personal and familyrelated stress was an important finding which suggests that ethnic family experience is not always positive and problem free. Because family bonding and reciprocity between generations is expected within the Hispanic culture (Markides & Krause 1985, 1986), it makes sense that family conflicts play an important role in explaining well-being. However, it is unclear why family conflict did not predict psychological distress among Puerto Rican elders. It has been suggested that Puerto Rican elders were more spiritual and accepting or tolerant of stress and problems (Garcia-Preto 1982). Furthermore, for Cuban American and Puerto Rican elders, concern about having to depend too much on other people may reflect two factors: worry about the availability of support when needed, and the tendency for these elders to seek only the help of children but not other relatives (Escovar & Kurtines 1983). On the other hand, it is difficult to tell whether concern about dependency was due to deterioration of familism or weakening of elder care values in the family. Because this is a cross-sectional study, it is difficult to draw conclusions regarding causality.
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These findings suggest several directions for improving the overall wellbeing of Hispanic elders. Practitioners need to be trained to understand the health-related, personal, and family stresses that are associated with the psychological distress of these elders. For service providers, it is important to recognize that the emotional well-being of Hispanic elders is closely tied to their functional impairment, health status, unmet service needs, gender, living arrangements, fear of dependence, and family conflicts. Consideration of these variables is essential to the design of culturally appropriate services for these three groups of Hispanic elders. The findings of the present study highlight the vulnerability of the three groups of Hispanic elders who are at risk of psychological distress. Further research should focus on understanding what kind of coping and social support factors could help to alleviate their psychological distress. The findings also point to the importance of considering national origin when serving and studying Hispanic elders.
Acknowledgments The author would like to thank the Inter-University Consortium for Political and Social Research for making the data available. The data for the national Survey of Hispanic Elderly People were originally collected by Karen Davis and the Commonwealth Fund. Neither the collector nor the Consortium can bear any responsibility for the analyses or interpretations presented in this paper.
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Address for correspondence: Ada C. Mui, PhD, ACSW, Columbia University, School of Social Work, 622 W. 113th Street, New York, NY 10025, USA Phone: (212)854 7394; Fax: (212) 854 2975; E-mail: [email protected]
