American Journal of Men's Health http://jmh.sagepub.com/
Risk and Protective Factors for Three Major Mental Health Problems Among Latino American Men Nationwide Amy L. Ai, Cara Pappas and Elena Simonsen Am J Mens Health published online 3 April 2014 DOI: 10.1177/1557988314528533 The online version of this article can be found at: http://jmh.sagepub.com/content/early/2014/04/01/1557988314528533
Published by: http://www.sagepublications.com
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528533 research-article2014
JMHXXX10.1177/1557988314528533American Journal of Men’s HealthAi et al.
Article
Risk and Protective Factors for Three Major Mental Health Problems Among Latino American Men Nationwide
American Journal of Men’s Health 1–12 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314528533 ajmh.sagepub.com
Amy L. Ai, PhD1, Cara Pappas, ND1, and Elena Simonsen1
Abstract The present study investigated psychosocial predictors for major depressive disorder (MDD), general anxiety disorder (GAD), and suicidal ideation (SI) of Latino American men identified in the first national mental health epidemiological survey of Latinos. Three separate sets of logistic regression analyses were performed for 1,127 Latinos, following preplanned two steps (Model 1—Known Demographic and Acculturation Predictors as controls, Model 2— Psychosocial Risk and Protective Factors). Results show that Negative Interactions with family members significantly predicted the likelihood of both MDD and SI, while SI was also associated with Discrimination. Acculturation Stress was associated with that of GAD (alongside more Income, Education of 12 years, and Years in the United States for less than 11 years). Other potential protective factors (social support, racial/ethnic identity, religious involvement) were not influential. The differential predictors for mental health issues among Latino men imply that assessment and intervention for them may need certain gender-specific foci in order to improve mental health disparities in this population. Keywords access to care, cultural disparity, depression, health inequality/disparity, Latino immigrants As one of the two fastest growing minority groups in the United States, Latino Americans are expected to comprise an estimated 30% of the national population in 2050 (U.S. Census Bureau, 2010). Research on Latinos’ mental health has incurred considerable growth over the past 8 years, since the population-based National Latino and Asian American Study (NLAAS) was made public (Alegria et al., 2004; Alegría et al., 2008). According to the NLAAS investigators, novel aims of the national survey were presented in data on (a) 12-month and lifetime prevalence of psychiatric disorders and the rates of mental health services utilization for Latino and Asian American populations; (b) associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and service utilization; and (c) comparison of 12-month and lifetime prevalence of psychiatric disorders, and utilization of Latinos and Asian Americans with representative samples of non-Latino White Americans (from the National Comorbidity Study–Replication [NCS-R]) and African Americans (from the National Survey of American Life [NSAL]). Despite the increased number of publications on the NLAAS, few studies have specifically focused on male Latinos (Ai, Noël, Appel, Huang, & Hefley, 2013).
In a descriptive analysis on the overall health of Latino men in the NLAAS, Ai et al. (2013) reported a 6.4% incidence of major depressive disorder (MDD) over the past 12 months with no subethnic group differences. MDD is characterized by a group of disorders occurring in discrete episodes of at least 2 weeks’ duration, or longer, and involving clear-cut changes in affect, cognition, and neurovegetative functions and interepisode remissions (American Psychiatric Association, 2013). The authors recommended further investigation with multivariate analyses to explore the impact of contributing factors to this psychiatric diagnosis and other health conditions. Expanding that study and also using the NLAAS database (Ai et al., 2013), the current analysis investigated the predictive value of psychosocial protective and risk factors for MDD, generalized anxiety disorder (GAD), and suicidal ideation (SI), above and beyond the role of 1
Florida State University, Tallahassee, FL, USA
Corresponding Author: Amy L. Ai, Departments of Family Medicine and Psychology, Colleges of Social Work and Nursing, Florida State University, 2313 University Building C, College of Social Work, Tallahassee, FL 32306, USA. Email: [email protected]
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predictors in the literature. GAD is characterized by excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities, associated with at least three of six symptoms (e.g., restlessness, difficulty concentrating, irritability; American Psychiatric Association, 2013). SI involves thoughts about suicide. Given the paucity of male-specific studies on Latinos nationwide, we begin with the significance of the study with previous findings on informed mental health disparity issues and key predictive factors (e.g., sociodemographics and acculturation variables) among all Latinos in the United States. We then present emerging evidence on psychosocial protective factors, mostly evident in the non–gender-specific studies. Finally, we delineate the study aims. The significance of this study may lie in the implications for the integrated health care for minorities. To date, mounting evidence suggests that comorbid mental health disorders play a critical role in chronic ailments and affect the efficiency of health care services in the United States. For example, research has consistently associated MDD and GAD with short- and long-term poor health outcomes, such as cardiovascular diseases (Ai, Rollman, & Berger, 2010; Pan, Sun, Okereke, Rexrode, & Hu, 2011; Whooley et al., 2008). As for the Latino population, Ortega, Feldman, Canino, Steinman, and Alegría (2006) related depression and cooccurring anxiety and depression both to a history of asthma. In addition, anxiety was linked with suffering from diabetes and cardiovascular disease, after controlling for demographics and immigration status or number of years in the United States. Addressing these mental health issues in the Latino men, primarily in the low-wage job market, may, thus, bear a considerable influence on their health disparities and health care service utilization in the future. Using Collaborative Psychiatric Epidemiology Studies (CPES), epidemiological research has documented mental health disparities among Latinos and other racial/ethnic minorities in the United States. Nicklett and Burgard (2009) linked Latino ethnicity, the female sex, a longer residency in the United States, and being a U.S. citizen with greater odds of major depressive episodes among immigrants to the United States in the national database. González, Tarraf, Whitfield, and Vega (2010) showed that Mexicans, alongside African Americans, reported significantly higher depression chronicity and lower depression care use compared with European Americans. However, Asnaani, Richey, Dimaite, Hinton, and Hofmann (2010) found that Latinos overall were less likely to meet the diagnoses for GAD and posttraumatic stress disorder than European and African Americans, respectively. An earlier analysis revealed varied lifetime prevalence of SIs and suicidal attempts, ranging from 4.4% to 10.2% across
Latino subgroups (Fortuna, Perez, Canino, Sribney, & Alegria, 2007). Borges, Orozco, Rafful, Miller, and Breslau (2012) found that non-Hispanic White Americans ranked the highest on SI, followed by Hispanics, nonHispanic Blacks and Asian Americans. The difference in rates of suicide attempt, however, was equally common among Latino, non-Hispanic Black, and non-Hispanic White Americans. To date, NLAAS publications have exhibited certain known predictors for Latinos’ mental health, which must be controlled for in the present study. An unemployed status was associated with MDD among all Latinos (Gavin et al., 2010) and, in particular, with psychiatric disorders among men of all minority subgroups (Chatterji, Alegria, & Takeuchi, 2009). U.S.-born and more acculturated Latinos (e.g., better English proficiency, third generation) had greater likelihood of being diagnosed with MDD and other psychiatric disorders (e.g., bipolar disorders, posttraumatic stress disorder) than immigrant Latinos (Alegría, Mulvaney-Day, Woo, & Torres, 2007; Alegría et al., 2008; Grant et al., 2005; Vega, Canino, Cao, & Alegria, 2009; Vega et al., 1998; Ortega, Canino, & Alegría, 2008). Odds of lifetime GAD were more prevalent in the bilingual group assigned to English than in the group interviewed in Spanish (Shrout et al., 2008). For Latino and other minorities, risk for suicide including ideations prior to migration was low among immigrants than the U.S.-born but was equalized over time after migration (Borges et al., 2012). Differences of SI across Latino subgroups were linked with or moderated by their lifetime Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) diagnoses (Fortuna et al., 2007). Zhang, Hong, Takeuchi, and Mossakowski (2012), however, displayed a stronger connection of sociodemographic variables and discrimination (an important acculturation factor for Latinos) with psychological distress than English proficiency in Latino and Asian Americans. Despite the recent evidence regarding known predictors and psychiatric disorders, there is still an insufficient understanding of Latinos’ m7ental health. Additional efforts should be made on culturally relevant psychosocial factors. One of the important goals of the NLAAS survey was attaining cultural relevance in contextual differences of Latinos as compared with the mainstream population. Emerging evidence suggests that the lower rate of anxiety disorders in Latinos, compared with those in European and African Americans, may partly be attributed to protective influences of certain psychosocial factors (e.g., racial/ethnic identity, social support, and religious involvement, operationalized as religious attendance and coping). Mulvaney-Day, Alegría, and Sribney (2007) demonstrated the benefit of a strong social network and social support for their physical and mental health.
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Ai et al. Robinson, Bolton, Rasic, and Sareen (2012) found that religious attendance contributed to the low odds of both anxiety and SI. Pérez, Fortuna, and Alegria (2008) indicated that Latinos holding greater racial/ethnic identity perceive less discrimination, compared with their counterparts who identified themselves less with Latinos. In another report, such identity significantly contributed to Latinos’ self-rated mental health and self-rated physical health, above and beyond the predictive value of known predictors (e.g., discrimination; Ai, Aisenberg, & Weiss, 2014). This study also replicated Robinson et al.’s (2012) finding concerning an optimal role of attendance in mental health. Among all psychosocial predictors, family-relevant factors may stand out as one most uniquely relevant to the Latino culture. Predominantly Catholics, the Latino population is characterized by the influence of collectivism in which family values play a central role in their ethnic identity and mental health (Ai, et al., 2014). Earlier reports found family discord to alleviate self-reported mental health and to accelerate the risk of mood disorders (Alegria, Shrout, et al., 2007; Mulvaney-Day et al., 2007). Those authors suggested that maintenance of family harmony, integration in advantageous U.S. neighborhoods, and positive perceptions of social standing are critical to successful adaptation into the United States. Indeed, Lorenzo-Blanco and Cortina (2013) associated acculturated Latinos with a pattern of frequently perceived discrimination, family conflict, and a lack of shared family values and cohesion. Family cohesion was identified as a protector against GAD in Latinos, in addition to the damage of family discord concerning all anxiety disorders (Priest & Denton, 2012). As a part of the acculturation process, family problems and discrimination, in turn, contributed to the greater likelihood for MDD. Currently, however, there is limited research evidence concerning the role of family factors (negative interaction and family coherence) among Latino men, alongside other potential protective factors (racial/ethnic identity, social support, and religious involvement). Latino male immigrants who assumed a culturally inherent role for their families (chief breadwinners) may face more distress within the personal autonomy-oriented culture in the United States (Arbona et al., 2010). As such, culturaltransmutation-based stressors may exert particular pressure on Latino men. In an earlier study, Canino, Vega, Sribney, Warner, and Alegría (2008) found that substance use disorders increased with problematic family relations for Latino men but not for Latin women. Based on the limited evidence, more gender-specific studies are required to better inform assessment and intervention for this growing prominent blue-collar workforce and the largest immigration group in the United States. The primary aim of our study is to address this gap through revealing the joint effect of psychosocial factors
on the likelihood of MDD, GAD, and SI among Latino men. To evaluate the predictive value of these factors, above and beyond the influence of existing demographic and acculturation predictors, we conducted logistic regression analyses controlling for those variables in the literature. The secondary aim was to take the study as a mirror analysis of our previous report in a Latin womenspecific multivariate analysis (Ai, Weiss, & Fichman, 2014) in order to draw cross-gender comparison in Latinos nationwide. In that study, we have found the prediction of negative interactions in their families for women’s GAD and SI but not for their MDD, while family cohesion appeared to protect them against GAD. Furthermore, negative interactions in part explained the detrimental impact of perceived discrimination on Latin women’s SI. Such a comparison between Latino men and Latin women may help inform the care service providers for this rapidly growing working force in the U.S. health industry.
Method Data Source and Procedure The study is a secondary data analysis using the NLAAS data set. The NLAAS is the first representative household survey on the mental health of Latino and Asian Americans residing in the United States. The study was designed as a part of the CPES that includes NLAAS, the NSAL, and the NCS-R. The aggregated data of CPES are partly aimed to compare the association of immigration factors and the use of mental health services across major racial and ethnic categories (African American, Asian American, and Latino Americans) with that of European Americans. The original research design of the NLAAS was thus adapted from that of the NCS-R (Alegria et al., 2004; Kessler et al., 2004). Available in six languages (e.g., English and Spanish), the NLAAS questionnaire provided the information on key sociodemographics, self-reported mental health diagnoses, service utilization, and acculturation variables for Latinos. The data were collected from May 2002 to December 2003 at various sittings by trained bilingual interviewers and aggregated at the University of Michigan. The total sample size in the NLAAS was 4,649, including 2,554 Latinos (aged 18 years or older) in three major subgroups (i.e., Cubans, Mexicans, and Puerto Ricans) and “Other” Latinos (e.g., Costa Ricans, Ecuadorans, Guatemalans, and Hondurans), all aged 18 years and older. This research project involved all 1,127 Latino men identified in the NLAAS. The NLAAS consists of primary sampling units selected with probabilities proportional to size with three stages of sampling that were described extensively elsewhere (Alegria et al., 2004; Heeringa et al., 2004).
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Weights were developed to correct for sampling bias for the total sample, using the interval estimates from other CPES studies. Specifically, the NLAAS employs Bayesian methods to produce weighted estimates (Heeringa et al., 2004). The public version of the NLAAS was released in 2004. Institutional review board approvals were gained and informed consent was received from all study participants in the initial NLAAS and also for this secondary analysis at the Florida State University. All computations were conducted using Stata 10 (StataCorp LP, College Station, TX). The weights created for the data are presented in the results, based on demographics social and economic variables to correct for sampling bias, including age.
Measures Dependent Variables as Criteria Mental health disorders. In the NLAAS, a diagnosis of MDD, GAD, or SI was recorded, based on the World Mental Health Survey Initiative version of the WMH-CIDI, equivalent to the criteria from the DSMIV (American Psychiatric Association, 1994; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998). Participants were asked whether they had had these diagnoses in their lives and over the past 12 months by interviewers, which were recorded as dichotomy variables (0 = no, 1 = yes). We used the 1-year rate in order to not introduce bias concerning the extent of life span toward younger respondents. Known Predictive Factors as Controls Sociodemographic predictors. In the Step-I multivariate analysis, we entered a set of four variables: Age (measured by years), Education (four levels: 1 = 0-11 years, 2 = 12 years, 3 = 13-15 years, and 4 = ≥16 years with 0-11 years served as the reference category), Income (ranging from 0 to 17; measured using an index as the ratio to poverty threshold—the U.S. Census’ Year 2000 poverty line), and Employment (two levels: 0 = unemployed or not in the labor force, 1 = employed). Acculturation predictors. Step I of the multivariate analysis also evaluated a set of five such variables. First, English Proficiency was based on an average of three items regarding levels of one’s ability to speak, read, and write English (α = 0.97). Second, U.S.-born was dichotomized (0 = foreign-born, 1 = U.S.-born). Third, Years in the United States was categorical (four levels: 0-10, 11-20, ≥21 years or more, and U.S.-born with 0-10 years in the United States served as the reference category). Fourth, Acculturation Stress (an averaged scale based on nine items with dichotomized answers; 0 = no, 1 = yes) assessed social and emotional strains pertaining to culture
change resultant from migration (Vega et al., 1998; α = 0.69). Finally, Discrimination (an average of nine questions on a 6-point scale for each; 1 = never, 6 = almost every day) measured daily perception of perceived discrimination (Gee, Spencer, Chen, Yip, & Takeuchi, 2007; α = 0.908). Independent Variables of Major Interests Risk and protective factors of major interests. The StepII analysis included a set of five psychosocial variables of major interest in this study: (a) Religious Involvement (Attendance or Coping; one item for each measure, respectively; for example, Attendance was measured on a 4-point scale, 1 = never, 2 = once a month, 3 = 1-3 times a month, and 4 = once a week or more with never served as the reference category); (b) Social Support (composed of eight variables measuring emotional support through spouses/partners, family, and friends; an averaged 4-point scale,1 = not at all; 4 = a lot; α = 0.783); (c) Negative Interactions (based on two items asking about past conflict with the respondent’s family; an averaged 4-point scale, 1 = never, 4 = often; α = 0.598); (d) Family Cohesiveness (consisting of three variables measuring the feeling of closeness to the respondent’s family; an averaged 4-point scale,1 = strongly disagree, 4 = strongly agree; α = 0.845); and (e) Racial and Ethnic Identity (based on three items measuring perceived closeness to the respondent’s ethnic group; an averaged 4-point scale; α = 0.749).
Statistical Analysis Descriptive analyses were computed for all variables among Latino men in this analysis. Kendall’s Tau statistics were conducted to illustrate the zero-order correlations between all variables in the multivariate analyses. Logistic regression analyses were conducted with dichotomous diagnostics as the criterion for three outcomes, respectively, involving two preplanned steps. Under each diagnosis, the first model included covariates (existing sociodemographics and acculturation predictors in the literature. The second included the investigation of psychosocial risk and protective factors in addition to the existing predictors in the first model. Religious Attendance and Coping were evaluated in two separate equations, following previous analyses; Ai, et al., 2014), and were presented in two models. In logistic regression, the odds ratios (ORs) indicate the likelihood that one group had the likelihood of occurrence in any diagnosis than another group. An OR >1 represents a positive relationship, and OR
Risk and Protective Factors for Three Major Mental Health Problems Among Latino American Men Nationwide Amy L. Ai, Cara Pappas and Elena Simonsen Am J Mens Health published online 3 April 2014 DOI: 10.1177/1557988314528533 The online version of this article can be found at: http://jmh.sagepub.com/content/early/2014/04/01/1557988314528533
Published by: http://www.sagepublications.com
Additional services and information for American Journal of Men's Health can be found at: Email Alerts: http://jmh.sagepub.com/cgi/alerts Subscriptions: http://jmh.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Apr 3, 2014 What is This?
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528533 research-article2014
JMHXXX10.1177/1557988314528533American Journal of Men’s HealthAi et al.
Article
Risk and Protective Factors for Three Major Mental Health Problems Among Latino American Men Nationwide
American Journal of Men’s Health 1–12 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314528533 ajmh.sagepub.com
Amy L. Ai, PhD1, Cara Pappas, ND1, and Elena Simonsen1
Abstract The present study investigated psychosocial predictors for major depressive disorder (MDD), general anxiety disorder (GAD), and suicidal ideation (SI) of Latino American men identified in the first national mental health epidemiological survey of Latinos. Three separate sets of logistic regression analyses were performed for 1,127 Latinos, following preplanned two steps (Model 1—Known Demographic and Acculturation Predictors as controls, Model 2— Psychosocial Risk and Protective Factors). Results show that Negative Interactions with family members significantly predicted the likelihood of both MDD and SI, while SI was also associated with Discrimination. Acculturation Stress was associated with that of GAD (alongside more Income, Education of 12 years, and Years in the United States for less than 11 years). Other potential protective factors (social support, racial/ethnic identity, religious involvement) were not influential. The differential predictors for mental health issues among Latino men imply that assessment and intervention for them may need certain gender-specific foci in order to improve mental health disparities in this population. Keywords access to care, cultural disparity, depression, health inequality/disparity, Latino immigrants As one of the two fastest growing minority groups in the United States, Latino Americans are expected to comprise an estimated 30% of the national population in 2050 (U.S. Census Bureau, 2010). Research on Latinos’ mental health has incurred considerable growth over the past 8 years, since the population-based National Latino and Asian American Study (NLAAS) was made public (Alegria et al., 2004; Alegría et al., 2008). According to the NLAAS investigators, novel aims of the national survey were presented in data on (a) 12-month and lifetime prevalence of psychiatric disorders and the rates of mental health services utilization for Latino and Asian American populations; (b) associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and service utilization; and (c) comparison of 12-month and lifetime prevalence of psychiatric disorders, and utilization of Latinos and Asian Americans with representative samples of non-Latino White Americans (from the National Comorbidity Study–Replication [NCS-R]) and African Americans (from the National Survey of American Life [NSAL]). Despite the increased number of publications on the NLAAS, few studies have specifically focused on male Latinos (Ai, Noël, Appel, Huang, & Hefley, 2013).
In a descriptive analysis on the overall health of Latino men in the NLAAS, Ai et al. (2013) reported a 6.4% incidence of major depressive disorder (MDD) over the past 12 months with no subethnic group differences. MDD is characterized by a group of disorders occurring in discrete episodes of at least 2 weeks’ duration, or longer, and involving clear-cut changes in affect, cognition, and neurovegetative functions and interepisode remissions (American Psychiatric Association, 2013). The authors recommended further investigation with multivariate analyses to explore the impact of contributing factors to this psychiatric diagnosis and other health conditions. Expanding that study and also using the NLAAS database (Ai et al., 2013), the current analysis investigated the predictive value of psychosocial protective and risk factors for MDD, generalized anxiety disorder (GAD), and suicidal ideation (SI), above and beyond the role of 1
Florida State University, Tallahassee, FL, USA
Corresponding Author: Amy L. Ai, Departments of Family Medicine and Psychology, Colleges of Social Work and Nursing, Florida State University, 2313 University Building C, College of Social Work, Tallahassee, FL 32306, USA. Email: [email protected]
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predictors in the literature. GAD is characterized by excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities, associated with at least three of six symptoms (e.g., restlessness, difficulty concentrating, irritability; American Psychiatric Association, 2013). SI involves thoughts about suicide. Given the paucity of male-specific studies on Latinos nationwide, we begin with the significance of the study with previous findings on informed mental health disparity issues and key predictive factors (e.g., sociodemographics and acculturation variables) among all Latinos in the United States. We then present emerging evidence on psychosocial protective factors, mostly evident in the non–gender-specific studies. Finally, we delineate the study aims. The significance of this study may lie in the implications for the integrated health care for minorities. To date, mounting evidence suggests that comorbid mental health disorders play a critical role in chronic ailments and affect the efficiency of health care services in the United States. For example, research has consistently associated MDD and GAD with short- and long-term poor health outcomes, such as cardiovascular diseases (Ai, Rollman, & Berger, 2010; Pan, Sun, Okereke, Rexrode, & Hu, 2011; Whooley et al., 2008). As for the Latino population, Ortega, Feldman, Canino, Steinman, and Alegría (2006) related depression and cooccurring anxiety and depression both to a history of asthma. In addition, anxiety was linked with suffering from diabetes and cardiovascular disease, after controlling for demographics and immigration status or number of years in the United States. Addressing these mental health issues in the Latino men, primarily in the low-wage job market, may, thus, bear a considerable influence on their health disparities and health care service utilization in the future. Using Collaborative Psychiatric Epidemiology Studies (CPES), epidemiological research has documented mental health disparities among Latinos and other racial/ethnic minorities in the United States. Nicklett and Burgard (2009) linked Latino ethnicity, the female sex, a longer residency in the United States, and being a U.S. citizen with greater odds of major depressive episodes among immigrants to the United States in the national database. González, Tarraf, Whitfield, and Vega (2010) showed that Mexicans, alongside African Americans, reported significantly higher depression chronicity and lower depression care use compared with European Americans. However, Asnaani, Richey, Dimaite, Hinton, and Hofmann (2010) found that Latinos overall were less likely to meet the diagnoses for GAD and posttraumatic stress disorder than European and African Americans, respectively. An earlier analysis revealed varied lifetime prevalence of SIs and suicidal attempts, ranging from 4.4% to 10.2% across
Latino subgroups (Fortuna, Perez, Canino, Sribney, & Alegria, 2007). Borges, Orozco, Rafful, Miller, and Breslau (2012) found that non-Hispanic White Americans ranked the highest on SI, followed by Hispanics, nonHispanic Blacks and Asian Americans. The difference in rates of suicide attempt, however, was equally common among Latino, non-Hispanic Black, and non-Hispanic White Americans. To date, NLAAS publications have exhibited certain known predictors for Latinos’ mental health, which must be controlled for in the present study. An unemployed status was associated with MDD among all Latinos (Gavin et al., 2010) and, in particular, with psychiatric disorders among men of all minority subgroups (Chatterji, Alegria, & Takeuchi, 2009). U.S.-born and more acculturated Latinos (e.g., better English proficiency, third generation) had greater likelihood of being diagnosed with MDD and other psychiatric disorders (e.g., bipolar disorders, posttraumatic stress disorder) than immigrant Latinos (Alegría, Mulvaney-Day, Woo, & Torres, 2007; Alegría et al., 2008; Grant et al., 2005; Vega, Canino, Cao, & Alegria, 2009; Vega et al., 1998; Ortega, Canino, & Alegría, 2008). Odds of lifetime GAD were more prevalent in the bilingual group assigned to English than in the group interviewed in Spanish (Shrout et al., 2008). For Latino and other minorities, risk for suicide including ideations prior to migration was low among immigrants than the U.S.-born but was equalized over time after migration (Borges et al., 2012). Differences of SI across Latino subgroups were linked with or moderated by their lifetime Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) diagnoses (Fortuna et al., 2007). Zhang, Hong, Takeuchi, and Mossakowski (2012), however, displayed a stronger connection of sociodemographic variables and discrimination (an important acculturation factor for Latinos) with psychological distress than English proficiency in Latino and Asian Americans. Despite the recent evidence regarding known predictors and psychiatric disorders, there is still an insufficient understanding of Latinos’ m7ental health. Additional efforts should be made on culturally relevant psychosocial factors. One of the important goals of the NLAAS survey was attaining cultural relevance in contextual differences of Latinos as compared with the mainstream population. Emerging evidence suggests that the lower rate of anxiety disorders in Latinos, compared with those in European and African Americans, may partly be attributed to protective influences of certain psychosocial factors (e.g., racial/ethnic identity, social support, and religious involvement, operationalized as religious attendance and coping). Mulvaney-Day, Alegría, and Sribney (2007) demonstrated the benefit of a strong social network and social support for their physical and mental health.
Downloaded from jmh.sagepub.com by guest on November 23, 2014
3
Ai et al. Robinson, Bolton, Rasic, and Sareen (2012) found that religious attendance contributed to the low odds of both anxiety and SI. Pérez, Fortuna, and Alegria (2008) indicated that Latinos holding greater racial/ethnic identity perceive less discrimination, compared with their counterparts who identified themselves less with Latinos. In another report, such identity significantly contributed to Latinos’ self-rated mental health and self-rated physical health, above and beyond the predictive value of known predictors (e.g., discrimination; Ai, Aisenberg, & Weiss, 2014). This study also replicated Robinson et al.’s (2012) finding concerning an optimal role of attendance in mental health. Among all psychosocial predictors, family-relevant factors may stand out as one most uniquely relevant to the Latino culture. Predominantly Catholics, the Latino population is characterized by the influence of collectivism in which family values play a central role in their ethnic identity and mental health (Ai, et al., 2014). Earlier reports found family discord to alleviate self-reported mental health and to accelerate the risk of mood disorders (Alegria, Shrout, et al., 2007; Mulvaney-Day et al., 2007). Those authors suggested that maintenance of family harmony, integration in advantageous U.S. neighborhoods, and positive perceptions of social standing are critical to successful adaptation into the United States. Indeed, Lorenzo-Blanco and Cortina (2013) associated acculturated Latinos with a pattern of frequently perceived discrimination, family conflict, and a lack of shared family values and cohesion. Family cohesion was identified as a protector against GAD in Latinos, in addition to the damage of family discord concerning all anxiety disorders (Priest & Denton, 2012). As a part of the acculturation process, family problems and discrimination, in turn, contributed to the greater likelihood for MDD. Currently, however, there is limited research evidence concerning the role of family factors (negative interaction and family coherence) among Latino men, alongside other potential protective factors (racial/ethnic identity, social support, and religious involvement). Latino male immigrants who assumed a culturally inherent role for their families (chief breadwinners) may face more distress within the personal autonomy-oriented culture in the United States (Arbona et al., 2010). As such, culturaltransmutation-based stressors may exert particular pressure on Latino men. In an earlier study, Canino, Vega, Sribney, Warner, and Alegría (2008) found that substance use disorders increased with problematic family relations for Latino men but not for Latin women. Based on the limited evidence, more gender-specific studies are required to better inform assessment and intervention for this growing prominent blue-collar workforce and the largest immigration group in the United States. The primary aim of our study is to address this gap through revealing the joint effect of psychosocial factors
on the likelihood of MDD, GAD, and SI among Latino men. To evaluate the predictive value of these factors, above and beyond the influence of existing demographic and acculturation predictors, we conducted logistic regression analyses controlling for those variables in the literature. The secondary aim was to take the study as a mirror analysis of our previous report in a Latin womenspecific multivariate analysis (Ai, Weiss, & Fichman, 2014) in order to draw cross-gender comparison in Latinos nationwide. In that study, we have found the prediction of negative interactions in their families for women’s GAD and SI but not for their MDD, while family cohesion appeared to protect them against GAD. Furthermore, negative interactions in part explained the detrimental impact of perceived discrimination on Latin women’s SI. Such a comparison between Latino men and Latin women may help inform the care service providers for this rapidly growing working force in the U.S. health industry.
Method Data Source and Procedure The study is a secondary data analysis using the NLAAS data set. The NLAAS is the first representative household survey on the mental health of Latino and Asian Americans residing in the United States. The study was designed as a part of the CPES that includes NLAAS, the NSAL, and the NCS-R. The aggregated data of CPES are partly aimed to compare the association of immigration factors and the use of mental health services across major racial and ethnic categories (African American, Asian American, and Latino Americans) with that of European Americans. The original research design of the NLAAS was thus adapted from that of the NCS-R (Alegria et al., 2004; Kessler et al., 2004). Available in six languages (e.g., English and Spanish), the NLAAS questionnaire provided the information on key sociodemographics, self-reported mental health diagnoses, service utilization, and acculturation variables for Latinos. The data were collected from May 2002 to December 2003 at various sittings by trained bilingual interviewers and aggregated at the University of Michigan. The total sample size in the NLAAS was 4,649, including 2,554 Latinos (aged 18 years or older) in three major subgroups (i.e., Cubans, Mexicans, and Puerto Ricans) and “Other” Latinos (e.g., Costa Ricans, Ecuadorans, Guatemalans, and Hondurans), all aged 18 years and older. This research project involved all 1,127 Latino men identified in the NLAAS. The NLAAS consists of primary sampling units selected with probabilities proportional to size with three stages of sampling that were described extensively elsewhere (Alegria et al., 2004; Heeringa et al., 2004).
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Weights were developed to correct for sampling bias for the total sample, using the interval estimates from other CPES studies. Specifically, the NLAAS employs Bayesian methods to produce weighted estimates (Heeringa et al., 2004). The public version of the NLAAS was released in 2004. Institutional review board approvals were gained and informed consent was received from all study participants in the initial NLAAS and also for this secondary analysis at the Florida State University. All computations were conducted using Stata 10 (StataCorp LP, College Station, TX). The weights created for the data are presented in the results, based on demographics social and economic variables to correct for sampling bias, including age.
Measures Dependent Variables as Criteria Mental health disorders. In the NLAAS, a diagnosis of MDD, GAD, or SI was recorded, based on the World Mental Health Survey Initiative version of the WMH-CIDI, equivalent to the criteria from the DSMIV (American Psychiatric Association, 1994; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998). Participants were asked whether they had had these diagnoses in their lives and over the past 12 months by interviewers, which were recorded as dichotomy variables (0 = no, 1 = yes). We used the 1-year rate in order to not introduce bias concerning the extent of life span toward younger respondents. Known Predictive Factors as Controls Sociodemographic predictors. In the Step-I multivariate analysis, we entered a set of four variables: Age (measured by years), Education (four levels: 1 = 0-11 years, 2 = 12 years, 3 = 13-15 years, and 4 = ≥16 years with 0-11 years served as the reference category), Income (ranging from 0 to 17; measured using an index as the ratio to poverty threshold—the U.S. Census’ Year 2000 poverty line), and Employment (two levels: 0 = unemployed or not in the labor force, 1 = employed). Acculturation predictors. Step I of the multivariate analysis also evaluated a set of five such variables. First, English Proficiency was based on an average of three items regarding levels of one’s ability to speak, read, and write English (α = 0.97). Second, U.S.-born was dichotomized (0 = foreign-born, 1 = U.S.-born). Third, Years in the United States was categorical (four levels: 0-10, 11-20, ≥21 years or more, and U.S.-born with 0-10 years in the United States served as the reference category). Fourth, Acculturation Stress (an averaged scale based on nine items with dichotomized answers; 0 = no, 1 = yes) assessed social and emotional strains pertaining to culture
change resultant from migration (Vega et al., 1998; α = 0.69). Finally, Discrimination (an average of nine questions on a 6-point scale for each; 1 = never, 6 = almost every day) measured daily perception of perceived discrimination (Gee, Spencer, Chen, Yip, & Takeuchi, 2007; α = 0.908). Independent Variables of Major Interests Risk and protective factors of major interests. The StepII analysis included a set of five psychosocial variables of major interest in this study: (a) Religious Involvement (Attendance or Coping; one item for each measure, respectively; for example, Attendance was measured on a 4-point scale, 1 = never, 2 = once a month, 3 = 1-3 times a month, and 4 = once a week or more with never served as the reference category); (b) Social Support (composed of eight variables measuring emotional support through spouses/partners, family, and friends; an averaged 4-point scale,1 = not at all; 4 = a lot; α = 0.783); (c) Negative Interactions (based on two items asking about past conflict with the respondent’s family; an averaged 4-point scale, 1 = never, 4 = often; α = 0.598); (d) Family Cohesiveness (consisting of three variables measuring the feeling of closeness to the respondent’s family; an averaged 4-point scale,1 = strongly disagree, 4 = strongly agree; α = 0.845); and (e) Racial and Ethnic Identity (based on three items measuring perceived closeness to the respondent’s ethnic group; an averaged 4-point scale; α = 0.749).
Statistical Analysis Descriptive analyses were computed for all variables among Latino men in this analysis. Kendall’s Tau statistics were conducted to illustrate the zero-order correlations between all variables in the multivariate analyses. Logistic regression analyses were conducted with dichotomous diagnostics as the criterion for three outcomes, respectively, involving two preplanned steps. Under each diagnosis, the first model included covariates (existing sociodemographics and acculturation predictors in the literature. The second included the investigation of psychosocial risk and protective factors in addition to the existing predictors in the first model. Religious Attendance and Coping were evaluated in two separate equations, following previous analyses; Ai, et al., 2014), and were presented in two models. In logistic regression, the odds ratios (ORs) indicate the likelihood that one group had the likelihood of occurrence in any diagnosis than another group. An OR >1 represents a positive relationship, and OR
