Article
Family Relations, Social Connections, and Mental Health Among Latino and Asian Older Adults
Research on Aging 2015, Vol. 37(2) 123–147 ª The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0164027514523298 roa.sagepub.com
Man Guo1, Shijian Li2, Jinyu Liu3, and Fei Sun4
Abstract Using a nationally representative sample, we compared Latino and Asian older adults in terms of lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and mood disorders. Given the strong family norms and collectivist cultures shared by the two groups, we also examined whether 12-month prevalence rates were associated with various family relation and social connection variables. The findings showed that older Latinos were almost twice as likely as older Asians to have any anxiety or mood disorders in their lifetime (34.5% vs. 17.7%) and in the past year (14.3% vs. 7.4%). Logistic regressions revealed different predictors of anxiety and mood disorders in the two groups: Family cultural conflict was associated with a higher prevalence of anxiety disorders, whereas family cohesion was associated with a lower prevalence of mood disorders. We argue that more research is needed on negative family interactions and their implications for the mental health of older ethnic minorities.
1
University of Iowa, School of Social Work, Iowa City, IA, USA State University of New York at Old Westbury, Health and Society, Old Westbury, NY, USA 3 University of Michigan, School of Social Work, Ann Arbor, MI, USA 4 Arizona State University, School of Social Work, Phoenix, AZ, USA 2
Corresponding Author: Man Guo, University of Iowa, School of Social Work, 354 North Hall, Iowa City, IA 52242, USA. Email: [email protected]
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Keywords anxiety disorders, mood disorders, family cultural conflict, family cohesion, immigration, Latinos, Asian Americans, older adults
Introduction Of the older racial/ethnic minorities in the United States, Latinos and Asians are the fastest growing groups. It is projected that between 2010 and 2050 there will be an approximate 513% and 464% increase in the older Latino and Asian populations, respectively, compared to increases of 199% and 61% among African American and White older adults, respectively (U.S. Census Bureau, 2008). By 2050, Latinos will be the largest older minority group (at 18 million), and the number of Asian older adults will reach more than 7 million (U.S. Census Bureau, 2008). Despite the exponential growth of the Latino and Asian older populations, studies of seniors’ mental health have been largely limited to Whites and African Americans (Evans-Campbell, Lincoln, & Takeuchi, 2007). Until recently, national studies on the mental health of Latino and Asian older adults have been rare (Woodward et al., 2012). The existing evidence shows higher rates of depressive symptoms among older Latinos and Asian Americans compared to their White counterparts (e.g., Gonza´lez, Tarraf, Whitfield, & Vega, 2010; Jang, Chiriboga, Kim, & Phillips, 2008; Kuo, Chong, & Joseph, 2008). However, much less is known about the prevalence and associates of other mental health disorders in the two groups. Given the rapid increase in the Latino and Asian older populations and their worse mental health, it is vital to study the prevalence, protective factors, and risk factors of various mental disorders in the two groups in order to reduce health disparities and to enhance successful aging among ethnic minorities. Although Latinos and Asians differ drastically in terms of their immigration histories and socioeconomic profiles, they share strong family norms and collectivist cultures (Ruiz, 2007). Both Latino and Asian cultures emphasize family solidarity and a sense of obligation to care for elders in multigenerational households. Familism, a cultural belief that stresses family cohesion, family loyalty, and family obligation, is a defining character of Latinos (Bermu´dez, Kirkpatrick, Hecker, & Torres-Robles, 2010). Similarly, the Confucian norm of filial piety indicates adult children’s obligations to care for older parents and is a central social norm of many Asian societies (Yee, Debaryshe, Yuen, Kim, & McCubbin, 2007). Latinos and Asians also
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share a fundamental self-view of interdependence in immediate communities (Goebert, 2009). Although the benefits of social support for older adults are well known, it is unclear whether the strong family and social ties experienced by Latinos and Asians function as protective factors against various types of adversity and potential mental disorders in later life. To address this research gap, we used a nationally representative sample to examine the lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-defined anxiety (i.e., generalized anxiety disorder [GAD], posttraumatic stress disorder [PTSD], social phobia, panic attack, panic disorder, and agoraphobia) and mood disorders (i.e., major depression and dysthymia) among Latino and Asian older adults. We were also interested in examining whether and how various family relation variables (i.e., family cohesion, family cultural conflict, and family support) and social connection variables (i.e., friend support and neighborhood cohesion) were related to the 12-month prevalence of anxiety and mood disorders in the two groups.
Description of the Problem The Mental Health of Latino and Asian Older Adults in the United States Latino and Asian older adults have different mental health needs than other older Americans. Many older Latinos have limited English language skills, which is a major barrier to their education, employment, and access to health and social services (Administration on Aging [AOA], 2010b). Latinos in general and older Latinos in particular continue to have difficult and stressful acculturation experiences, sometimes accompanied by feelings of being second class (Gonzalez, 2007). All of these factors have a pervasive influence on their daily lives, contributing to mental distress. National and regional studies have consistently reported higher past-week (13.2%–30%) and 12-month (8.6%–10.8%) prevalence rates of depression among Latinos than non-Latino Whites (past week: 9%–16%; 12 month: 5.3%–7.8%; Black, Markides, & Miller, 1998; Dunlop, Song, Lyons, Manheim, & Chang, 2003; Gonza´lez, Haan, & Hinton, 2001; Jang et al., 2008; Moscicki, Locke, Rae, & Boyd, 1989; Vernon & Roberts, 1982). However, the lifetime prevalence of depression seems to be comparable for Latinos (15.2%–17%) and Whites (16.8%–16.9%; Jimenez, Alegrı´a, Chen, Chan, & Laderman, 2010; Woodward et al., 2012). Studies on depression in older Latinos have identified some risk factors, including low income, a low level of acculturation,
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caregiving burden, poor support networks, and exposure to trauma such as high crime rates and political violence (L. Hinton & Area´n, 2008). Similar to their Latino counterparts, older Asians often experience a great deal of stress associated with immigration, acculturation, discrimination, and prejudice (Kuo et al., 2008). Early Asian immigrants, such as the Japanese, the Chinese, and Filipinos, shared the experience of racism, isolation, and laws against Asians that characterized the early 20th century (AOA, 2010a). More recent refugees from Southeast Asia are at greater risk for PTSD as a result of political torture and loss of significant others before and after immigrating to the United States (Moon & Cho, 2012). These demeaning experiences may be internalized, having negative consequences on mental health in later life. A review of 24 studies of depression in older Asian immigrants (OAIs) reported higher prevalence rates of depression among OAIs (ranging from 4.2% to 44.8%) than community-dwelling general older adults (18%–20%; Kuo et al., 2008). The common correlates of depression in OAIs include female gender, poor physical health, economic strain, social isolation, recent immigration, and a lack of English proficiency (Kuo et al., 2008). Research on anxiety in both Latino and Asian older adults is sparse. To date, only two recent studies have examined the issue using data from national epidemiologic surveys (Jimenez et al., 2010; Woodward et al., 2012). Both studies reported a higher lifetime prevalence of any anxiety disorders, GAD, and social phobia in Whites and Latinos than in Asians and African Americans. The racial/ethnic differences were less consistent for other anxiety disorders, such as panic disorder, PTSD, and agoraphobia. Overall, Latinos tended to have a higher prevalence of agoraphobia, and Asians had the lowest rates of all anxiety disorders among the four racial/ethnic groups. Although the two studies shed important light on the mental health of older ethnic minorities, both focused on younger people (aged 50þ in Jimenez et al., 2010; aged 55þ in Woodward et al., 2012), instead of using more commonly used age cutoffs for older populations (e.g., 60þ or 65þ). It is noteworthy that the social categories of Latino and Asian both represent enormous internal heterogeneity based on demographic and social characteristics such as ethnic identity, nativity, socioeconomic status (SES), immigration history, acculturation, religion, language, and life experience (Choi, 2000; L. Hinton & Area´n, 2008; Woodward et al., 2012). Such internal heterogeneity, however, does not contradict the fact that both Latinos and Asians share common values and norms, such as strong extended family networks, collectivism, respect for elders, and greater interdependence among family members (Kim & McKenry, 1998). In one study, when SES factors were controlled, there were more similarities than differences in family
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support and social network across ethnic minority groups (Kim & McKenry, 1998). We now discuss the strong family and social ties shared by older Latinos and Asians, which can be important predictors of mental health in later life.
Family Relations and Social Connections Among Latino and Asian Older Adults Ecological system theory depicts the mutual accommodation between individuals and the changing environment, which is composed of nested structures, including micro-, meso-, exo-, macro-, and chronosystems (Bronfenbrenner, 1979). Family and neighborhood represent the microsystem that constitutes the immediate environment in which individuals engage in face-to-face interactions. They powerfully shape one’s psychological well-being through intimate interpersonal relationships (Bronfenbrenner, 1979, 1986). As older adults retire from work, family and neighborhood become the most important microsystem settings in which they participate in daily activities, play different roles, and maintain the most immediate relationships. Perceptions of these relationships, either positive or negative, substantially affect older adults’ adaptation to the environment and consequently shape their mental health outcomes. Because of cultural preferences, economic constraints, and linguistic isolation, families, friends, and ethnic communities are inextricably linked with the well-being of older immigrants/ethnic minorities (Treas, 2008). Close and supportive family relations and social connections help protect the mental health of older immigrants/ethnic minorities by mitigating stress, reducing social isolation, and enhancing access to social and health services (Krause, 2001). Both Latino and Asian older adults tend to have larger family networks than Whites and African Americans, and they are more likely to seek assistance from their children in an emergency (de Leon & Glass, 2004; Kim & McKenry, 1998). Latino families are often portrayed as cohesive, with a deep sense of reciprocal family obligations in multigenerational households (Bermu´dez et al., 2010). Asian families share these interdependent family norms with their Latino counterparts. For instance, compared to other ethnic groups, Chinese and Korean elders have fewer sources of support than their adult children and tend to turn first to their children for support (Wong, Yoo, & Stewart, 2007). Maintaining close and supportive family relations is associated with lower risks of psychiatric disorders in both Latino and Asian older adults (Lopez et al., 2004; Mulvaney-Day, Alegria, & Sribney, 2007). However, little is known about whether the greater interdependence of family members in the
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two groups can be a source of tension, conflict, or disappointment or whether it can compromise the mental health of older adults. Among older immigrants in particular, family conflicts often occur as a result of cultural differences in values and lifestyles across the generations (Glick, 2010). Not exposed to the acculturating experience of work and school as their offspring are, older adults face more difficulties learning a new language and adapting to new cultural norms. Family cultural conflicts caused by different acculturation levels across generations have a detrimental influence on the mental health of both Latino and Asian older adults (Lee, Choe, Kim, & Ngo, 2000; Mulvaney-Day et al., 2007; Rivera et al., 2008). Power and authority dynamics also shift in immigrant/ethnic minority families as a result of the acculturation process. Older parents often lose authority that they used to have and tend to become peripheral to the nuclear family (Wong, Yoo, & Stewart, 2006). For instance, discord in values between older parents and their children lead older Asians to feel stripped of their role as ‘‘wisdom givers’’ and transmitters of cultural heritage (Guglani, Coleman, & Sonuga-Barke, 2000). Friends compose another important dimension of social support for older adults. Support from friends is crucial to older adults who are experiencing challenges and difficulties related to immigration (Wong et al., 2006). Having same-age friends helped Chinese older immigrants to establish support networks for mutual help and information sharing and to maintain customs and values in the new country (Tsai & Lopez, 1998). Research similarly showed that a lack of friends or support from friends was directly related to depression in Latino immigrants (Almeida, Subramanian, Kawachi, & Molnar, 2011; Vega, Kolody, & Valle, 1987). Findings were inconsistent regarding whether friend or family support was more powerful in predicting depression in Latino immigrants (Almeida et al., 2011; Vega et al., 1987). Immediate neighborhoods are important for older adults because of their decreased physical and cognitive functioning, increased discomfort with driving, and decreased contact with social network members (Yen, Michael, & Perdue, 2009). A cohesive and supportive neighborhood is particularly important for older immigrants who spend most of their time in the ethnic community. Latino enclave communities offer social resources to their members and have a salutary impact on health (Eschbach, Ostir, Patel, Markides, & Goodwin, 2004). Similarly, ethnic communities facilitate the adjustment of older Asian American immigrants to the new environment and increase their sense of well-being by providing religious and health care services, outlets for socialization and recreation with peers, and informational and instrumental support (Choi, 2000).
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Purpose The evidence reviewed thus far indicates higher risks of depression in both Latino and Asian older adults and a higher prevalence of anxiety disorders among Latino older adults compared to their White counterparts. Overall, older Asians are overlooked in cross-cultural studies. In Kuo, Chong, and Joseph’s (2008) review of Asian elders’ depression, only 3 of the 24 studies used probability sampling. More efforts are also needed to understand the influence of mental health on the strong family relations and social connections of the two groups. The present study used a nationally representative sample of Latino and Asian older adults to address two research questions: (a) What are the lifetime and 12-month prevalence rates of DSM-IV-defined anxiety and mood disorders among the two groups? (b) Do family relations and social connections affect the 12-month prevalence of anxiety and mood disorders among the two groups? It was hypothesized that the prevalence of anxiety and mood disorders would be lower among those with greater family cohesion, less family cultural conflict, greater support from family and friends, and greater neighborhood cohesion.
Method Data This study used data from a nationally representative survey, the National Latino and Asian American Study (NLAAS, 2002–2003), which aimed to understand the prevalence of psychiatric disorders, family and social factors associated with these disorders, and mental health service utilization among adult Latinos and Asian Americans. The sampling design of NLAAS included three components: a nationally representative sample of primary and secondary sampling units, a high-density supplemental sampling of geographic areas where Asian or Latino ethnic groups made up more than 5% of the population, and a second respondent sampling from households in which a primary respondent had been interviewed (Alegrı´a et al., 2004; Heeringa et al., 2004). To qualify for the study, individuals had to have been 18 years of age or older, to self-identify as Latino or Asian American, and to reside in households in the 50 states or Washington, DC. Race and ethnicity were assessed by self-report responses to categories identical to those used in the 2000 Census. Trained interviewers with linguistic and cultural backgrounds similar to those of the respondents administered the survey face-to-face in the
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respondents’ preferred language. On average, the survey took 2.5 hr to complete. The final NLAAS sample consisted of 4,649 adults, of whom 2,095 were Asian American. The weighted response rates were 73.2% for the total sample, 75.5% for the Latino sample, and 65.6% for the Asian sample (Heeringa et al., 2004). To ensure that the sample was nationally representative, the NLAAS survey team developed sampling weights based on factors such as unequal probabilities of selection, characteristics of nonresponse, and poststratification. For the purpose of this study, we restricted our analytical sample to individuals aged 60 and older (N ¼ 616), which included 360 Latinos and 256 Asians.
Measures Psychiatric disorders. The NLAAS measures of psychiatric disorders were based on diagnostic interview using the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI; Pennell et al., 2004; World Health Organization, 1998). The Spanish and Asian versions of the CIDI went through an intensive process of translation and adaptation to ensure cross-cultural equivalency in semantic, content, and criterion/conceptual perspectives (Alegrı´a et al., 2004). The NLAAS data contained separate diagnoses of each of the six anxiety disorders (i.e., GAD, PTSD, social phobia, panic attack, panic disorder, and agoraphobia) and two mood disorders (i.e., major depressive episode and dysthymia). In this study, we included dichotomous variables indicating whether the respondent met diagnostic criteria for any of the six anxiety disorders (1 ¼ yes, 0 ¼ no) or any of the two mood disorders (1 ¼ yes, 0 ¼ no) in his or her lifetime and in the past 12 months, respectively. Family relations and social connections. Family relations and social connections were the major independent variables in this study. Family relations consisted of three composite scales: family cohesion, family cultural conflict, and family support. Social connections consisted of two composite scales: friend support and neighborhood cohesion. All scales were additive scores of relevant items, with higher scores reflecting higher levels of the construct measured. The family cohesion scale (weighted mean ¼ 37.24 for Latinos, 37.52 for Asians, range ¼ 10–40) was derived from 10 items that assessed respondents’ sense of family by asking respondents how strongly they agreed or disagreed with the following: Family members respect one another, share similar values and beliefs as a family, work well as a family, trust and confide
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in each other, feel loyal to the family, are proud of family, express feelings with family, like to spend free time with each other, and feel very close to each other and family togetherness is very important. The response categories were strongly disagree, somewhat disagree, somewhat agree, and strongly agree. The 10 items loaded on one factor with a Cronbach’s a of .93. The family cultural conflict scale (weighted mean ¼ 6.03 for Latinos, 6.27 for Asians, range ¼ 5–15) was drawn from a subscale of the Hispanic Stress Inventory (Cervantes, Padilla, & Salgado de Snyder, 1991). The 5 items asked whether the respondent had ever felt that being too close to family interfered with goals, felt lonely and isolated due to a lack of family unity, felt that family relations were less important to people close to him or her, had family conflict due to different customs, or had family conflict due to different personal goals. The response categories were hardly ever or never, sometimes, and often. The 5 items loaded on one factor above .67, with a Cronbach’s a of .79. Family and friend support measured the degree of support received in these two domains. The family support scale (weighted mean ¼ 9.26 for Latinos, 7.79 for Asians, range ¼ 3–12) contained 3 items assessing the extent of reliance on extended family or relatives for emotional support. The questions asked (a) how often respondents talked on the phone or got together with relatives, (b) how much they could rely on relatives for help with a serious problem, and (c) how much they could open up to family and talk about worries. For each item, the responses were coded into one of four categories: once a month or less, a few times a month, a few times a week, or almost every day. The Cronbach’s a for the items was .74. The friend support scale (weighted mean ¼ 7.51 for Latinos, 6.74 for Asians, range ¼ 3–12) used three parallel questions to those in the family support scale, with the words ‘‘family’’ or ‘‘relatives’’ replaced by ‘‘friends.’’ The friend items loaded on a single factor with a Cronbach’s a of .76. The neighborhood cohesion scale (weighted mean ¼ 13.00 for Latinos, 13.16 for Asians, range ¼ 4–16) contained four questions asking whether people in the neighborhood could be trusted, got along with each other, helped in an emergency, and looked out for each other. The four response categories ranged from not at all true to very true. All items loaded on a single factor, and Cronbach’s a was more than .80. Covariates. We included three blocks of covariates that have been shown to be correlated with mental health risks in older minorities. They were (a) demographic characteristics (race, age, gender, and marital status), (b) SES (education and annual household income) and health status (self-rated health),
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and (c) immigration-related factors (nativity/length of residency in the United States and English language ability). Age was a continuous variable ranging from 60 to 99. Gender, marital status, and race were dichotomous variables with men ¼ 1, married/partnered ¼ 1, and Latino ¼ 1, respectively. Education levels were less than high school or high school graduate, some college, and university graduate or more. Annual household income included the following four categories: US$0–$24,999, US$25,000– $49,999, US$50,000–$99,999, and US$100,000þ. Self-rated health was collapsed into three categories (fair/poor, good, and very good/excellent). Nativity/length of residency was coded into four categories: native born, in the United States for less than 10 years, in the United States for 11–20 years, and in the United States for more than 20 years. English language proficiency was assessed by asking the question ‘‘How well do you speak English?’’ Responses were poor, fair, good, and excellent.
Analysis We first estimated the weighted sample characteristics of Latino and Asian older adults followed by examinations of the lifetime and 12-month prevalence of the six anxiety and the two mood disorders. Given that family relations and social connections change over the lifetime, we conducted multistage logistic regressions to examine the associations of 12-month prevalence of anxiety and mood disorders, respectively, using the combined sample of Asians and Latinos. The three sets of variables mentioned previously were entered sequentially in regressions. This sequence enabled us to evaluate the unique contribution of family relations and social connections on individual well-being while segregating the possible effects triggered by sociodemographic and immigration-related variables. We normalized the indicators of family relations and social connections to have a mean of 0 and a standard deviation of 1 in the sample. All analyses took into account design effects (e.g., stratification and clustering) by using the svy family commands of Stata 11.0 (StataCorp, 2011).
Results Table 1 presents weighted characteristics of the sample. Asian elders were more likely than Latino elders to be married. They also had significantly more education, higher income, and better self-rated health. Although a higher percentage of Latino elders were either native born or had been in the United States for more than 20 years, they reported poorer English
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Table 1. Weighted Sample Characteristics of Asian and Latino Older Adults Aged 60 and Older in National Latino and Asian American Study. Asian elders (N ¼ 256)
Characteristics
Mean/ percentage (%)
Demographic variables Age Female (%) Married/partnered (%) Socioeconomic and health status Education (%) Less than high school/high school graduate Some college University graduate or more Annual household income (%) US$0–24,999 US$25,000–49,999 US$50,000–99,999 US$100,000 and above Self-rated health (%) Fair/poor Good Very good/excellent Immigration-related variables Nativity and length of residence in the U.S.-born Stay in the United States for more than 20 years Stay in the United States for 11–20 years Stay in the United States for 10 years or less English language proficiency (%) Poor Fair Good Excellent
69.56 55.10 72.37
SD
Latino elders (N ¼ 360) Mean/ percentage (%)
8.25
69.63 56.91 54.04
p SD Valuea 7.02
.99 .67
Family Relations, Social Connections, and Mental Health Among Latino and Asian Older Adults
Research on Aging 2015, Vol. 37(2) 123–147 ª The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0164027514523298 roa.sagepub.com
Man Guo1, Shijian Li2, Jinyu Liu3, and Fei Sun4
Abstract Using a nationally representative sample, we compared Latino and Asian older adults in terms of lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and mood disorders. Given the strong family norms and collectivist cultures shared by the two groups, we also examined whether 12-month prevalence rates were associated with various family relation and social connection variables. The findings showed that older Latinos were almost twice as likely as older Asians to have any anxiety or mood disorders in their lifetime (34.5% vs. 17.7%) and in the past year (14.3% vs. 7.4%). Logistic regressions revealed different predictors of anxiety and mood disorders in the two groups: Family cultural conflict was associated with a higher prevalence of anxiety disorders, whereas family cohesion was associated with a lower prevalence of mood disorders. We argue that more research is needed on negative family interactions and their implications for the mental health of older ethnic minorities.
1
University of Iowa, School of Social Work, Iowa City, IA, USA State University of New York at Old Westbury, Health and Society, Old Westbury, NY, USA 3 University of Michigan, School of Social Work, Ann Arbor, MI, USA 4 Arizona State University, School of Social Work, Phoenix, AZ, USA 2
Corresponding Author: Man Guo, University of Iowa, School of Social Work, 354 North Hall, Iowa City, IA 52242, USA. Email: [email protected]
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Keywords anxiety disorders, mood disorders, family cultural conflict, family cohesion, immigration, Latinos, Asian Americans, older adults
Introduction Of the older racial/ethnic minorities in the United States, Latinos and Asians are the fastest growing groups. It is projected that between 2010 and 2050 there will be an approximate 513% and 464% increase in the older Latino and Asian populations, respectively, compared to increases of 199% and 61% among African American and White older adults, respectively (U.S. Census Bureau, 2008). By 2050, Latinos will be the largest older minority group (at 18 million), and the number of Asian older adults will reach more than 7 million (U.S. Census Bureau, 2008). Despite the exponential growth of the Latino and Asian older populations, studies of seniors’ mental health have been largely limited to Whites and African Americans (Evans-Campbell, Lincoln, & Takeuchi, 2007). Until recently, national studies on the mental health of Latino and Asian older adults have been rare (Woodward et al., 2012). The existing evidence shows higher rates of depressive symptoms among older Latinos and Asian Americans compared to their White counterparts (e.g., Gonza´lez, Tarraf, Whitfield, & Vega, 2010; Jang, Chiriboga, Kim, & Phillips, 2008; Kuo, Chong, & Joseph, 2008). However, much less is known about the prevalence and associates of other mental health disorders in the two groups. Given the rapid increase in the Latino and Asian older populations and their worse mental health, it is vital to study the prevalence, protective factors, and risk factors of various mental disorders in the two groups in order to reduce health disparities and to enhance successful aging among ethnic minorities. Although Latinos and Asians differ drastically in terms of their immigration histories and socioeconomic profiles, they share strong family norms and collectivist cultures (Ruiz, 2007). Both Latino and Asian cultures emphasize family solidarity and a sense of obligation to care for elders in multigenerational households. Familism, a cultural belief that stresses family cohesion, family loyalty, and family obligation, is a defining character of Latinos (Bermu´dez, Kirkpatrick, Hecker, & Torres-Robles, 2010). Similarly, the Confucian norm of filial piety indicates adult children’s obligations to care for older parents and is a central social norm of many Asian societies (Yee, Debaryshe, Yuen, Kim, & McCubbin, 2007). Latinos and Asians also
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share a fundamental self-view of interdependence in immediate communities (Goebert, 2009). Although the benefits of social support for older adults are well known, it is unclear whether the strong family and social ties experienced by Latinos and Asians function as protective factors against various types of adversity and potential mental disorders in later life. To address this research gap, we used a nationally representative sample to examine the lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-defined anxiety (i.e., generalized anxiety disorder [GAD], posttraumatic stress disorder [PTSD], social phobia, panic attack, panic disorder, and agoraphobia) and mood disorders (i.e., major depression and dysthymia) among Latino and Asian older adults. We were also interested in examining whether and how various family relation variables (i.e., family cohesion, family cultural conflict, and family support) and social connection variables (i.e., friend support and neighborhood cohesion) were related to the 12-month prevalence of anxiety and mood disorders in the two groups.
Description of the Problem The Mental Health of Latino and Asian Older Adults in the United States Latino and Asian older adults have different mental health needs than other older Americans. Many older Latinos have limited English language skills, which is a major barrier to their education, employment, and access to health and social services (Administration on Aging [AOA], 2010b). Latinos in general and older Latinos in particular continue to have difficult and stressful acculturation experiences, sometimes accompanied by feelings of being second class (Gonzalez, 2007). All of these factors have a pervasive influence on their daily lives, contributing to mental distress. National and regional studies have consistently reported higher past-week (13.2%–30%) and 12-month (8.6%–10.8%) prevalence rates of depression among Latinos than non-Latino Whites (past week: 9%–16%; 12 month: 5.3%–7.8%; Black, Markides, & Miller, 1998; Dunlop, Song, Lyons, Manheim, & Chang, 2003; Gonza´lez, Haan, & Hinton, 2001; Jang et al., 2008; Moscicki, Locke, Rae, & Boyd, 1989; Vernon & Roberts, 1982). However, the lifetime prevalence of depression seems to be comparable for Latinos (15.2%–17%) and Whites (16.8%–16.9%; Jimenez, Alegrı´a, Chen, Chan, & Laderman, 2010; Woodward et al., 2012). Studies on depression in older Latinos have identified some risk factors, including low income, a low level of acculturation,
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caregiving burden, poor support networks, and exposure to trauma such as high crime rates and political violence (L. Hinton & Area´n, 2008). Similar to their Latino counterparts, older Asians often experience a great deal of stress associated with immigration, acculturation, discrimination, and prejudice (Kuo et al., 2008). Early Asian immigrants, such as the Japanese, the Chinese, and Filipinos, shared the experience of racism, isolation, and laws against Asians that characterized the early 20th century (AOA, 2010a). More recent refugees from Southeast Asia are at greater risk for PTSD as a result of political torture and loss of significant others before and after immigrating to the United States (Moon & Cho, 2012). These demeaning experiences may be internalized, having negative consequences on mental health in later life. A review of 24 studies of depression in older Asian immigrants (OAIs) reported higher prevalence rates of depression among OAIs (ranging from 4.2% to 44.8%) than community-dwelling general older adults (18%–20%; Kuo et al., 2008). The common correlates of depression in OAIs include female gender, poor physical health, economic strain, social isolation, recent immigration, and a lack of English proficiency (Kuo et al., 2008). Research on anxiety in both Latino and Asian older adults is sparse. To date, only two recent studies have examined the issue using data from national epidemiologic surveys (Jimenez et al., 2010; Woodward et al., 2012). Both studies reported a higher lifetime prevalence of any anxiety disorders, GAD, and social phobia in Whites and Latinos than in Asians and African Americans. The racial/ethnic differences were less consistent for other anxiety disorders, such as panic disorder, PTSD, and agoraphobia. Overall, Latinos tended to have a higher prevalence of agoraphobia, and Asians had the lowest rates of all anxiety disorders among the four racial/ethnic groups. Although the two studies shed important light on the mental health of older ethnic minorities, both focused on younger people (aged 50þ in Jimenez et al., 2010; aged 55þ in Woodward et al., 2012), instead of using more commonly used age cutoffs for older populations (e.g., 60þ or 65þ). It is noteworthy that the social categories of Latino and Asian both represent enormous internal heterogeneity based on demographic and social characteristics such as ethnic identity, nativity, socioeconomic status (SES), immigration history, acculturation, religion, language, and life experience (Choi, 2000; L. Hinton & Area´n, 2008; Woodward et al., 2012). Such internal heterogeneity, however, does not contradict the fact that both Latinos and Asians share common values and norms, such as strong extended family networks, collectivism, respect for elders, and greater interdependence among family members (Kim & McKenry, 1998). In one study, when SES factors were controlled, there were more similarities than differences in family
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support and social network across ethnic minority groups (Kim & McKenry, 1998). We now discuss the strong family and social ties shared by older Latinos and Asians, which can be important predictors of mental health in later life.
Family Relations and Social Connections Among Latino and Asian Older Adults Ecological system theory depicts the mutual accommodation between individuals and the changing environment, which is composed of nested structures, including micro-, meso-, exo-, macro-, and chronosystems (Bronfenbrenner, 1979). Family and neighborhood represent the microsystem that constitutes the immediate environment in which individuals engage in face-to-face interactions. They powerfully shape one’s psychological well-being through intimate interpersonal relationships (Bronfenbrenner, 1979, 1986). As older adults retire from work, family and neighborhood become the most important microsystem settings in which they participate in daily activities, play different roles, and maintain the most immediate relationships. Perceptions of these relationships, either positive or negative, substantially affect older adults’ adaptation to the environment and consequently shape their mental health outcomes. Because of cultural preferences, economic constraints, and linguistic isolation, families, friends, and ethnic communities are inextricably linked with the well-being of older immigrants/ethnic minorities (Treas, 2008). Close and supportive family relations and social connections help protect the mental health of older immigrants/ethnic minorities by mitigating stress, reducing social isolation, and enhancing access to social and health services (Krause, 2001). Both Latino and Asian older adults tend to have larger family networks than Whites and African Americans, and they are more likely to seek assistance from their children in an emergency (de Leon & Glass, 2004; Kim & McKenry, 1998). Latino families are often portrayed as cohesive, with a deep sense of reciprocal family obligations in multigenerational households (Bermu´dez et al., 2010). Asian families share these interdependent family norms with their Latino counterparts. For instance, compared to other ethnic groups, Chinese and Korean elders have fewer sources of support than their adult children and tend to turn first to their children for support (Wong, Yoo, & Stewart, 2007). Maintaining close and supportive family relations is associated with lower risks of psychiatric disorders in both Latino and Asian older adults (Lopez et al., 2004; Mulvaney-Day, Alegria, & Sribney, 2007). However, little is known about whether the greater interdependence of family members in the
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two groups can be a source of tension, conflict, or disappointment or whether it can compromise the mental health of older adults. Among older immigrants in particular, family conflicts often occur as a result of cultural differences in values and lifestyles across the generations (Glick, 2010). Not exposed to the acculturating experience of work and school as their offspring are, older adults face more difficulties learning a new language and adapting to new cultural norms. Family cultural conflicts caused by different acculturation levels across generations have a detrimental influence on the mental health of both Latino and Asian older adults (Lee, Choe, Kim, & Ngo, 2000; Mulvaney-Day et al., 2007; Rivera et al., 2008). Power and authority dynamics also shift in immigrant/ethnic minority families as a result of the acculturation process. Older parents often lose authority that they used to have and tend to become peripheral to the nuclear family (Wong, Yoo, & Stewart, 2006). For instance, discord in values between older parents and their children lead older Asians to feel stripped of their role as ‘‘wisdom givers’’ and transmitters of cultural heritage (Guglani, Coleman, & Sonuga-Barke, 2000). Friends compose another important dimension of social support for older adults. Support from friends is crucial to older adults who are experiencing challenges and difficulties related to immigration (Wong et al., 2006). Having same-age friends helped Chinese older immigrants to establish support networks for mutual help and information sharing and to maintain customs and values in the new country (Tsai & Lopez, 1998). Research similarly showed that a lack of friends or support from friends was directly related to depression in Latino immigrants (Almeida, Subramanian, Kawachi, & Molnar, 2011; Vega, Kolody, & Valle, 1987). Findings were inconsistent regarding whether friend or family support was more powerful in predicting depression in Latino immigrants (Almeida et al., 2011; Vega et al., 1987). Immediate neighborhoods are important for older adults because of their decreased physical and cognitive functioning, increased discomfort with driving, and decreased contact with social network members (Yen, Michael, & Perdue, 2009). A cohesive and supportive neighborhood is particularly important for older immigrants who spend most of their time in the ethnic community. Latino enclave communities offer social resources to their members and have a salutary impact on health (Eschbach, Ostir, Patel, Markides, & Goodwin, 2004). Similarly, ethnic communities facilitate the adjustment of older Asian American immigrants to the new environment and increase their sense of well-being by providing religious and health care services, outlets for socialization and recreation with peers, and informational and instrumental support (Choi, 2000).
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Purpose The evidence reviewed thus far indicates higher risks of depression in both Latino and Asian older adults and a higher prevalence of anxiety disorders among Latino older adults compared to their White counterparts. Overall, older Asians are overlooked in cross-cultural studies. In Kuo, Chong, and Joseph’s (2008) review of Asian elders’ depression, only 3 of the 24 studies used probability sampling. More efforts are also needed to understand the influence of mental health on the strong family relations and social connections of the two groups. The present study used a nationally representative sample of Latino and Asian older adults to address two research questions: (a) What are the lifetime and 12-month prevalence rates of DSM-IV-defined anxiety and mood disorders among the two groups? (b) Do family relations and social connections affect the 12-month prevalence of anxiety and mood disorders among the two groups? It was hypothesized that the prevalence of anxiety and mood disorders would be lower among those with greater family cohesion, less family cultural conflict, greater support from family and friends, and greater neighborhood cohesion.
Method Data This study used data from a nationally representative survey, the National Latino and Asian American Study (NLAAS, 2002–2003), which aimed to understand the prevalence of psychiatric disorders, family and social factors associated with these disorders, and mental health service utilization among adult Latinos and Asian Americans. The sampling design of NLAAS included three components: a nationally representative sample of primary and secondary sampling units, a high-density supplemental sampling of geographic areas where Asian or Latino ethnic groups made up more than 5% of the population, and a second respondent sampling from households in which a primary respondent had been interviewed (Alegrı´a et al., 2004; Heeringa et al., 2004). To qualify for the study, individuals had to have been 18 years of age or older, to self-identify as Latino or Asian American, and to reside in households in the 50 states or Washington, DC. Race and ethnicity were assessed by self-report responses to categories identical to those used in the 2000 Census. Trained interviewers with linguistic and cultural backgrounds similar to those of the respondents administered the survey face-to-face in the
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respondents’ preferred language. On average, the survey took 2.5 hr to complete. The final NLAAS sample consisted of 4,649 adults, of whom 2,095 were Asian American. The weighted response rates were 73.2% for the total sample, 75.5% for the Latino sample, and 65.6% for the Asian sample (Heeringa et al., 2004). To ensure that the sample was nationally representative, the NLAAS survey team developed sampling weights based on factors such as unequal probabilities of selection, characteristics of nonresponse, and poststratification. For the purpose of this study, we restricted our analytical sample to individuals aged 60 and older (N ¼ 616), which included 360 Latinos and 256 Asians.
Measures Psychiatric disorders. The NLAAS measures of psychiatric disorders were based on diagnostic interview using the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI; Pennell et al., 2004; World Health Organization, 1998). The Spanish and Asian versions of the CIDI went through an intensive process of translation and adaptation to ensure cross-cultural equivalency in semantic, content, and criterion/conceptual perspectives (Alegrı´a et al., 2004). The NLAAS data contained separate diagnoses of each of the six anxiety disorders (i.e., GAD, PTSD, social phobia, panic attack, panic disorder, and agoraphobia) and two mood disorders (i.e., major depressive episode and dysthymia). In this study, we included dichotomous variables indicating whether the respondent met diagnostic criteria for any of the six anxiety disorders (1 ¼ yes, 0 ¼ no) or any of the two mood disorders (1 ¼ yes, 0 ¼ no) in his or her lifetime and in the past 12 months, respectively. Family relations and social connections. Family relations and social connections were the major independent variables in this study. Family relations consisted of three composite scales: family cohesion, family cultural conflict, and family support. Social connections consisted of two composite scales: friend support and neighborhood cohesion. All scales were additive scores of relevant items, with higher scores reflecting higher levels of the construct measured. The family cohesion scale (weighted mean ¼ 37.24 for Latinos, 37.52 for Asians, range ¼ 10–40) was derived from 10 items that assessed respondents’ sense of family by asking respondents how strongly they agreed or disagreed with the following: Family members respect one another, share similar values and beliefs as a family, work well as a family, trust and confide
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in each other, feel loyal to the family, are proud of family, express feelings with family, like to spend free time with each other, and feel very close to each other and family togetherness is very important. The response categories were strongly disagree, somewhat disagree, somewhat agree, and strongly agree. The 10 items loaded on one factor with a Cronbach’s a of .93. The family cultural conflict scale (weighted mean ¼ 6.03 for Latinos, 6.27 for Asians, range ¼ 5–15) was drawn from a subscale of the Hispanic Stress Inventory (Cervantes, Padilla, & Salgado de Snyder, 1991). The 5 items asked whether the respondent had ever felt that being too close to family interfered with goals, felt lonely and isolated due to a lack of family unity, felt that family relations were less important to people close to him or her, had family conflict due to different customs, or had family conflict due to different personal goals. The response categories were hardly ever or never, sometimes, and often. The 5 items loaded on one factor above .67, with a Cronbach’s a of .79. Family and friend support measured the degree of support received in these two domains. The family support scale (weighted mean ¼ 9.26 for Latinos, 7.79 for Asians, range ¼ 3–12) contained 3 items assessing the extent of reliance on extended family or relatives for emotional support. The questions asked (a) how often respondents talked on the phone or got together with relatives, (b) how much they could rely on relatives for help with a serious problem, and (c) how much they could open up to family and talk about worries. For each item, the responses were coded into one of four categories: once a month or less, a few times a month, a few times a week, or almost every day. The Cronbach’s a for the items was .74. The friend support scale (weighted mean ¼ 7.51 for Latinos, 6.74 for Asians, range ¼ 3–12) used three parallel questions to those in the family support scale, with the words ‘‘family’’ or ‘‘relatives’’ replaced by ‘‘friends.’’ The friend items loaded on a single factor with a Cronbach’s a of .76. The neighborhood cohesion scale (weighted mean ¼ 13.00 for Latinos, 13.16 for Asians, range ¼ 4–16) contained four questions asking whether people in the neighborhood could be trusted, got along with each other, helped in an emergency, and looked out for each other. The four response categories ranged from not at all true to very true. All items loaded on a single factor, and Cronbach’s a was more than .80. Covariates. We included three blocks of covariates that have been shown to be correlated with mental health risks in older minorities. They were (a) demographic characteristics (race, age, gender, and marital status), (b) SES (education and annual household income) and health status (self-rated health),
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and (c) immigration-related factors (nativity/length of residency in the United States and English language ability). Age was a continuous variable ranging from 60 to 99. Gender, marital status, and race were dichotomous variables with men ¼ 1, married/partnered ¼ 1, and Latino ¼ 1, respectively. Education levels were less than high school or high school graduate, some college, and university graduate or more. Annual household income included the following four categories: US$0–$24,999, US$25,000– $49,999, US$50,000–$99,999, and US$100,000þ. Self-rated health was collapsed into three categories (fair/poor, good, and very good/excellent). Nativity/length of residency was coded into four categories: native born, in the United States for less than 10 years, in the United States for 11–20 years, and in the United States for more than 20 years. English language proficiency was assessed by asking the question ‘‘How well do you speak English?’’ Responses were poor, fair, good, and excellent.
Analysis We first estimated the weighted sample characteristics of Latino and Asian older adults followed by examinations of the lifetime and 12-month prevalence of the six anxiety and the two mood disorders. Given that family relations and social connections change over the lifetime, we conducted multistage logistic regressions to examine the associations of 12-month prevalence of anxiety and mood disorders, respectively, using the combined sample of Asians and Latinos. The three sets of variables mentioned previously were entered sequentially in regressions. This sequence enabled us to evaluate the unique contribution of family relations and social connections on individual well-being while segregating the possible effects triggered by sociodemographic and immigration-related variables. We normalized the indicators of family relations and social connections to have a mean of 0 and a standard deviation of 1 in the sample. All analyses took into account design effects (e.g., stratification and clustering) by using the svy family commands of Stata 11.0 (StataCorp, 2011).
Results Table 1 presents weighted characteristics of the sample. Asian elders were more likely than Latino elders to be married. They also had significantly more education, higher income, and better self-rated health. Although a higher percentage of Latino elders were either native born or had been in the United States for more than 20 years, they reported poorer English
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Table 1. Weighted Sample Characteristics of Asian and Latino Older Adults Aged 60 and Older in National Latino and Asian American Study. Asian elders (N ¼ 256)
Characteristics
Mean/ percentage (%)
Demographic variables Age Female (%) Married/partnered (%) Socioeconomic and health status Education (%) Less than high school/high school graduate Some college University graduate or more Annual household income (%) US$0–24,999 US$25,000–49,999 US$50,000–99,999 US$100,000 and above Self-rated health (%) Fair/poor Good Very good/excellent Immigration-related variables Nativity and length of residence in the U.S.-born Stay in the United States for more than 20 years Stay in the United States for 11–20 years Stay in the United States for 10 years or less English language proficiency (%) Poor Fair Good Excellent
69.56 55.10 72.37
SD
Latino elders (N ¼ 360) Mean/ percentage (%)
8.25
69.63 56.91 54.04
p SD Valuea 7.02
.99 .67
