Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004) / Chapter Skim
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13 Cumulative Psychosocial Risks and Resilience: A Conceptual Perspective on Ethnic Health Disparities in Late Life
13 Cumulative Psychosocial Risks and Resilience: A Conceptual Perspective on Ethnic Health Disparities in Late Life
Pages 492-539
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From page 492... ...
Moreover, we provide a conceptual framework for understanding the relationships among ethnicity, age, and well-being for elderly minority populations. Specifically, we present a biopsychosocial model of cumulative psychological and physical vulnerability and resilience in later life in which chronic stress burden and psychosocial resources for coping are hypothesized as playing a significant role in accounting for ethnic disparities in mental health.
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From page 493... ...
Karel (1997) noted that low prevalence rates of major depression among older adults may reflect (1)
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From page 494... ...
. ETHNIC DISPARITIES IN DEPRESSION Results from large epidemiological studies on ethnic differences in the prevalence of major depression in the United States are mixed, with African Americans and Asian Americans showing lower rates of major depressive disorder (MDD)
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From page 495... ...
Results from the more recent NCS also confirmed the existence of some ethnic and gender differences in the prevalence of MDD (Blazer et al., 1994) , with whites and Hispanics evidencing higher lifetime rates of major depression than African Americans, and women in all ethnic groups evidencing consistently higher rates than men (see Table 13-1)
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From page 496... ...
Although rates of 30-day current major depression proved to be less stable, they revealed similar trends. Other studies have found no significant differences in prevalence of depression between African Americans and whites, but have found that depression in African Americans is associated with socioeconomic deprivation, including low urbanization, low education, chronic physical condition, uncertainty, job loss, money problems, and social isolation (Dressler and Badger, 1985)
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From page 497... ...
These rates of PTSD and alcohol use and/or dependence are much higher than for whites, African Americans, and Japanese Americans. ETHNIC DIFFERENCES IN DEPRESSION AMONG THE ELDERLY There is a surprising lack of research available on the psychological well-being of older ethnic minorities.
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From page 498... ...
. Additionally, the large majority of African Americans with major depression did not seek or receive mental health treatment (over 90 percent)
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From page 499... ...
There are relatively few studies on psychological distress and depression in elderly Asians and Asian Americans. The most frequently cited of these studies is the Chinese American Psychiatric Epidemiological Study, which found that Chinese Americans between the ages of 50 and 65 were at the greatest risk for becoming depressed (Takeuchi et al., 1998)
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From page 500... ...
On the other hand, African Americans and Asian Americans seem to have lower rates of diagnosable disorders, but higher rates of depressive symptomatology overall. Differences in the samples studied (i.e., community versus clinical samples)
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From page 501... ...
burden of psychosocial adversities, which is hypothesized to be the primary predictor of risk. Primary among these adversities are a cluster of life stresses that include chronic life stresses, major life events, ethnicity-related stresses, and age-related stresses.
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(3) events stresses events lifestyle coping lifestyle religiosity cumulative stresses of lifestyle coping lifestyle supports religiosity life of supports life -related of - -risk -risk advantages adversities vulnerabilities advantages resilience Psychosocial adversities Chronic Major nRacism/discriminatio History deprivation deprivation Aging stresses stresses Psychological vulnerabilities Psychosocial Flexible Psychological resilience Healthy Social Intrinsic High Psychosocial Flexible Psychological Healthy Social Intrinsic Psychosocial Chronic Major Racism/discrimination History Aging-related Psychological High model risk risk and factors and risks factors histories risks factors factors histories Biopsychosocial (2)
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From page 503... ...
cumulative adversities or vulnerabilities and (9) cumulative advantages or assets over the life-course and the life transitions experienced that ultimately contributes to differences in functional status and health trajectories in the elderly, both overall and as a function of ethnicity, gender, and social class.
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From page 504... ...
There is also a growing body of evidence that has specifically tested the hypothesis that ethnic differences in physical health may be due, at least in part, to differential exposure to chronic and acute life stressors (Geronimus, 1992; Williams et al., 1997)
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Furthermore, Zambrana and colleagues (1999) found that prenatal stress, drug use and smoking, and attitudes toward the pregnancy accounted for ethnic differences in birthweight between African Americans and Hispanics.
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, may have long-term deleterious effects that may become evident in their later years. Elderly African Americans were young adults during the Jim Crow years and the civil rights struggles, many elderly Japanese experienced internment camps, many elderly Mexican Americans experienced the Bracero Movement and the Zoot Suit riots in California, Cuban elders experienced economic losses when forced to leave Cuba followed by racism when they arrived in the United States, and most Native American elders experienced some of the worst treatment by the U.S.
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From page 507... ...
Additional studies are needed to investigate these hypotheses and to consider possible ethnic differences in exposure to and impact of racism-related stresses. Acculturative Stress Another major source of stress for racial/ethnic minority groups, especially those who are immigrants, is acculturative stress.
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. For minority elderly, acculturation may pose unique challenges.
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From page 509... ...
Aging-Related Stresses In addition to the stresses already described, the elderly face a number of additional stressors related to their life stage. These include adequacy and stability of financial resources, coping with chronic illnesses and the attendant pain and physical limitations, social isolation, assuming caretaking responsibilities for ill spouses or custodial responsibilities for grandchildren, loss of meaningful social roles, decreasing cognitive functioning and dementia, and reductions in their social networks due to death, especially of spouses and friends (Karel, 1997)
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From page 510... ...
Similarly, these grandparents were almost twice as likely as noncaregiving grandparents to report clinically significant levels of depressive symptoms, even after controlling for precaregiving depression and demographic characteristics (Minkler et al., 1997)
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From page 511... ...
Several studies have noted, however, that although the additional stress burden associated with assuming caregiving responsibilities for grandchildren increases risk for psychological distress and depression in all groups, there are notable ethnic differences in the relative impact this new source of stress appears to have. In a recent report, Pruchno (1999)
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From page 512... ...
Therefore, an important priority for future research is to investigate the contributions of chronic stress burden from multiple sources to the health trajectory and functional status of these understudied populations. ALLOSTATIC LOAD AS A BIOBEHAVIORAL MEDIATOR OF RISK Modern models of stress, disease, and functional status all acknowledge the importance of identifying the biological pathways through which the burden of life stresses contributes to differences in functional status and health outcomes.
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Those with higher relative disadvantages (i.e., negative economic and social relationships, at each measurement point) , especially those with persistent negative social relationships, evidenced higher allostatic loads (i.e., impaired immune function, elevated blood pressure, and later life illness and chronic disease propensity)
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From page 514... ...
also identified a group of resilient elderly who evidenced lower allostatic loads despite relatively disadvantaged histories, which they attributed to the presence of compensatory social relationship histories. This is an understudied group, especially resilient minority elders, which could yield valuable information for programs designed to foster healthy aging and that might help to close the health disparities gap.
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From page 515... ...
Additional research is needed to explore this hypothesis with the other ethnic groups and to determine whether women who experience adverse birth outcomes during their childbearing years evidence early aging in the form of more health difficulties and a heavier burden of medical morbidity in later years. We believe our understanding of the health disparities would be greatly enhanced by lifespan developmental studies that apply the concepts and methodologies used to test the allostatic load and weathering hypotheses to investigate ethnic differences in health trajectories.
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From page 516... ...
. Unfortunately, there continues to be inadequate representation of minority elderly in studies investigating factors associated with psychological resilience, especially groups other than African Americans.
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From page 517... ...
Some studies suggest that minorities evidence greater reliance on informal sources of help than whites (Harden, Clark, and Maguire, 1997; Zhang, Snowden, and Sue, 1998) , while others indicate that some groups, especially African Americans, tend to rely more on both formal and informal sources of support for mental health needs than whites (Snowden, 1998)
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From page 518... ...
a single-minded determination to succeed. When compared to higher SES African Americans and whites from all SES groups, John Henryism has been shown to predict higher blood pressure and greater risk for hypertension only in young African-American men with low socioeconomic resources (Dressler, Bindon, and Neggers, 1998; James, 1994)
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From page 519... ...
; better self-rated health, both cross-sectionally and over time; and lower risk for hypertension and lower cancer rates, especially in those religions that have strong dietary and other lifestyle restrictions. The evidence for participation and functional status are less clear because of possible reverse causation, but longitudinal studies do suggest that service attendance does influence functional health.
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From page 520... ...
Historically, African Americans and Hispanics have relied on religion and on the church as important sources of spiritual, emotional, and material support in coping with life stresses. In the case of African Americans, the church has also served as a powerful political force for social change and an opportunity for social status (Ellison, 1995)
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From page 521... ...
Taken as a whole, the evidence suggests that religion is an important spiritual and social resource for the elderly of all ethnic groups, and that African Americans and other minority elderly evidence greater religious involvement and use of religious coping than white elderly. However, the evidence also indicates that religion does not yield uniformly positive effects, especially as a buffer for depression and feelings of well-being.
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From page 522... ...
Additionally, most of the comparison studies of religiosity and health have been conducted on African Americans and whites, and there are comparatively fewer empirical studies that examined the effects of religiosity on mental health in Native Americans and Asian Americans, which should be an important priority for future research. Social Support Resources There is a substantial body of evidence examining the importance of social relationships and availability of adequate instrumental and emotional support on health.
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From page 523... ...
SUMMARY AND RECOMMENDATIONS FOR FUTURE RESEARCH In summary, our goal was to offer a multidimensional biopsychosocial framework for understanding the complex relationships among psychosocial, biological, and behavioral adversities and advantages that operate over the lifespan to impact the health and well-being of the elderly. Special attention was paid to identifying some of the primary risks and resources that are likely to be implicated in racial/ethnic differences in health and well-being in late life.
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From page 524... ...
Regardless of ethnicity, greater psychological distress and depression are found in elderly who are older, carrying a heavier burden of medical morbidity and functional impairment, more socially isolated, and who have few family and friend social supports. Higher rates are also found in those who have little perceived control over their circumstances, who fail to use more adaptive and flexible coping strategies, whose autonomy is constrained by their circumstances, who cope with frequent interpersonal conflicts, and who rely heavily on religious coping or have little or no religious or spiritual connections (Diehl et al., 1996; Karel, 1997; Musick et al., 2000; Nelson, 1989)
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From page 525... ...
As noted previously, although our review focused specifically on the role these hypothesized risk and protective factors play in accounting for individual and group differences in psychological distress, depression, and well-being, the proposed conceptual perspective should also be useful in investigating health disparities for a variety of other chronic diseases, including but not limited to essential hypertension and other cardiovascular diseases, chronic pain, cognitive decline and dementia, and functional impairment. Future research should consider the following priority issues: · Ethnic-specific studies are needed that investigate which psychosocial risk and protective factors are the most important contributors to psychological well-being and resilience in each racial/ethnic group.
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From page 526... ...
Particular attention should be given to the relationships among lifetime exposure to chronic life stresses, personality dispositions, coping styles, access to and utilization of social supports and formal services, and spirituality and religious participation. · Additionally, the investigation of ethnic disparities in health also raises a number of important statistical issues.
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From page 527... ...
· Finally, studies are also needed to identify factors that predict successful aging and healthy functional status in populations of color. This is perhaps the most understudied issue in the field.
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From page 528... ...
. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey.
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From page 529... ...
. Major depression in a community sample of African Americans.
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From page 530... ...
. Suicidality in older African Americans: Findings from the EPOCH study.
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From page 531... ...
. Participation in and outcome of treatment for major depression among low income Asian Americans.
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From page 532... ...
. A new perspective on the relationships among race, social class and psychological distress.
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. Obesity in African Americans: Biobehavioral consequences of cul ture.
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American Journal of Public Health, 89(9)
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. Ethnic differences in intrinsic/extrinsic religious orientation and depres sion in the elderly.
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. Price of adaptation -- allostatic load and its health consequences: MacArthur studies of successful aging.
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. Social relationships, social support, and patterns of cognitive aging in healthy, high functioning older adults: MacArthur studies of successful aging.
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. Ethnic differences in the perception of barriers to help-seeking.
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From page 539... ...
American Indian Alaska Native Mental Health Research, 6(2)
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