From the Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, CO.
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ABSTRACT |
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aging; depression; Hispanic Americans; rural health
Abbreviations: CES-D, Center for Epidemiologic Studies Depression Scale; SLVHAS, San Luis Valley Health and Aging Study.
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INTRODUCTION |
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Few studies examined depression in rural areas or included rural Hispanic elderly persons. O'Hara et al. (6) reported a 9 percent prevalence of depressive symptoms in rural, non-Hispanic White, older adults in Iowa. Stallones et al. (10
) studied depression in rural, mostly non-Hispanic White Colorado farmers and noted that older farmers were less likely than younger farmers to be depressed. Murrell et al. (1
) found more depression in rural, elderly, White and Black Kentucky men than in urban men but no differences in the women. A review of studies of urban-rural differences in psychiatric disorders by Mueller (11
) found more depression in urban areas but cautioned that case detection, control of sociodemographic variables, and types of urban-rural comparisons varied across studies, and that selective migration might affect levels of depressive disorder. Although social support levels may be lower in urban areas, rural residence may actually result in isolation from close friends and family for older persons (11
, 12
).
In 1997, 4.9 percent of the US population over age 65 was Hispanic and was projected to grow faster than any other group of elderly persons during the next three decades (13). Diversity within the US Hispanic population makes it difficult to generalize about this ethnic group (14
). Several studies of depression in older Hispanic adults, using various measurement methods, reported depression in 1140 percent of participants (2
, 15
17
). Studies have generally reported higher levels of depressive symptoms in ethnic minorities compared with non-Hispanic Whites and usually attributed this to higher levels of depression risk factors (1
, 2
, 14
, 17
19
). Lower language acculturation has been associated with more depressive symptoms in Hispanic adults of all ages (2
, 14
, 16
, 18
), though Moscicki et al. (17
) reported more depressive symptoms in higher acculturated Hispanic adults in the Hispanic Health and Nutrition Examination Survey. The present analysis examines the prevalence and risk factors associated with depressive symptoms in Hispanic and non-Hispanic White participants in the San Luis Valley Health and Aging Study (SLVHAS), conducted in 19931995 to measure functional impairment and disability in a geographically based sample of persons over age 60, in rural Colorado.
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MATERIALS AND METHODS |
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A sample of 1,982 noninstitutionalized, community-dwelling residents was selected from the two study counties following a complete household enumeration in 19921993 (97.2 percent response rate). To be eligible, persons had to be aged 60 years or over, of Hispanic or non-Hispanic White ethnicity, and a resident of one of the two counties. Nursing home residents were included in the study but not in these depression analyses. Hispanic residents and older age groups were oversampled to facilitate planned contrasts. Sixty-one percent of non-Hispanic Whites and 87 percent of Hispanics were invited to participate. Before a visit could be completed, 307 persons became ineligible and 317 refused to participate. Of those who became ineligible, 168 died before completing a study visit, 125 had moved out of the study area, and 14 had incorrect coding of age or ethnicity. Of the nonresponders, 192 (61 percent) completed a refusal interview. Nonresponders were more likely to be non-Hispanic White or older than age 80, and they were less likely to report difficulties with activities of daily living (23). Of the sample, 1,358 persons (81.1 percent) completed a visit. Subjects for this analysis were respondents with a Folstein Mini-Mental State Examination (MMSE) (24
) score of
18, who answered
90 percent of the depression questionnaire (n = 1,151). Those with a Mini-Mental State Examination score of <18 did not complete a depression questionnaire.
After informed consent was obtained, standardized questionnaires and examinations that assessed sociodemographic and cultural factors, health, use of health and social services, functional impairment, and medication use were administered by trained, bilingual interviewers during a 3- to 4-hour visit at the subject's home or at the study clinic. Fourteen percent of participants completed the interviews all or mostly in Spanish. All components of the study visit were approved by the University of Colorado Health Sciences Center's Institutional Review Board.
Depression measure
The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure the level of current (past week) depressive symptoms (25). The 20-item CES-D is not a diagnostic instrument but does measure the important symptoms of depression. The possible range of scores is 060, and 16 or higher is typically used to define high depressive symptoms (25
, 26
). In the case of one or two missing items, a reweighted total score was estimated using an item average.
The CES-D has been used with a variety of age, racial, and ethnic groups (including Hispanics) and has demonstrated high validity and reliability (8, 25
, 27
). Reliability was assessed in 60 subjects by administering a second questionnaire an average of 10 days after the first CES-D, by the same interviewer. The overall intraclass correlation was 0.81 (0.76 in non-Hispanic Whites and 0.86 in Hispanics). The CES-D was translated into Spanish and reviewed for local Spanish variations.
Other measures
Hispanic ethnicity was classified using the 1980 US Census question, "Are you of Spanish or Hispanic origin or descent?" (28, p. E-3). Education was self-reported as the total number of years of schooling. Income was self-reported as total pretax household income during the past year.
The chronic disease count was calculated from self-report of a diagnosis of 17 chronic diseases, including cancer, heart attack, transient ischemic attack, major stroke, angina, Parkinson's disease, congestive heart failure, chronic obstructive pulmonary disease, cirrhosis, renal failure, osteoporosis, seizures, current migraine headaches, blood vessel surgery or angioplasty since age 50, diabetes, arthritis, or hypertension. A medication inventory was completed on all subjects. The medical history included a question about the use of mental health professionals (psychologist, psychiatrist, or mental health counselor) during the past year.
Sociocultural variables included satisfaction with social support, household size, group activity participation, and, in Hispanics, acculturation level. Satisfaction with social support was measured by two items from Patrick's Perceived Quality of Life Scale: "How satisfied are you with how often you see or talk with your family and friends?" and "How satisfied are you with the help you get from family and friends?" (29, p. 219). Each question was rated by the participant on a scale from 0 to 10, where 0 was very dissatisfied and 10 was very satisfied. The responses to the two questions were combined for a possible total score of 020. The scores were dichotomized, based on their frequency, as "very satisfied" (1720 points) or "less satisfied" (016 points). Participation in any social, church, or volunteer activity, at least once per month, was used to classify group activity.
Acculturation was measured using an adaptation of the scale developed by Hazuda et al. (30). In the earlier San Luis Valley Diabetes Study (31
), conducted in this population, the acculturation scale used 29 of the original 31 questions of Hazuda et al. and included minor wording changes that made the questions more locally relevant. Using confirmatory factor analysis, the authors established that this instrument was performing similarly in this population of rural Hispanic persons, across the age range, compared with Hispanic persons in urban San Antonio (32
). A shorter instrument for use in the SLVHAS was developed without any loss of goodness-of-fit. The abbreviated set of 17 questions assesses all of the original domains including first language learned, languages used in various situations, self-assessment of English and Spanish competency, and attitudes about family roles and structures. The range of the abbreviated scale is 039. The acculturation score was categorized in tertiles based on the scores in this sample (range, 1335).
Analyses
Data were analyzed using the Statistical Analysis System (SAS) version 6.12 for Windows (SAS Institute, Inc., Cary, North Carolina). Crude prevalence estimates of depressive symptoms and population characteristics were tabulated, and chi-square tests were used to test for subgroup patterns. Logistic regression was done using PROC LOGISTIC (SAS Institute, Inc.). Interaction tests between ethnicity and the independent variables, by sex, were conducted to investigate whether patterns of high depressive symptoms (CES-D 16) were similar in both ethnic groups.
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RESULTS |
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DISCUSSION |
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Factors associated with higher levels of depressive symptoms were similar to those of other studies of older adults and included chronic health problems, living alone, lower income and education, less satisfaction with social support, and lack of involvement in group activities (13
, 5
7
, 9
, 16
). These factors operated similarly in the two ethnic groups. Consistent with other studies, age alone was not associated with depressive symptoms in either ethnic group (3
, 7
). Unlike most studies, female gender was significantly associated with more depressive symptoms only in Hispanic participants. Berkman et al. (5
) reported more depressive symptoms in non-Hispanic White women aged 6584 years but noted that, after age 85, the men reported more depressive symptoms.
Certain protective factors, for example, social support, may be more available in this rural setting and could account for the relatively low level of depressive symptoms, despite the prevalence of other factors that are associated with more depressive symptoms. For example, although more than 40 percent of the total sample (30 percent of non-Hispanic White and 53 percent of Hispanic participants) reported incomes below $10,000 per year, both ethnic groups also reported a high level of satisfaction with their social support that may offset the negative effect of lower income. Religion is an important feature of life in the region that may protect against depression (33) and provide social and material support. It is also possible that persons at risk of depressive symptoms were more likely to migrate out of the area to seek specialized health care or to live with children. Migration pattern effects may be detected prospectively.
There were no ethnic differences in depressive symptoms in the men, but Hispanic women were more likely to report high depressive symptoms than were non-Hispanic White women. Adjustment for age and acculturation level alone, and with multiple other risk factors, removed most of the increased odds ratio of depressive symptoms in Hispanic women in the highest acculturation stratum but not in the middle and lowest acculturation strata. Since the overall prevalence of high depressive symptoms was over 10 percent, the odds ratio may overestimate the prevalence risk ratio of high depressive symptoms. To address this concern, a corrected prevalence ratio estimate, for Hispanic compared with non-Hispanic White women, was calculated for the three acculturation strata using the method of Zhang and Yu (34). The estimated prevalence ratios were slightly lower but did not alter the pattern or significance of increased depressive symptoms in Hispanic women in the low and moderate acculturation strata (corrected prevalence estimate for low acculturation = 2.19, 95 percent confidence interval: 1.10, 3.93; for moderate acculturation = 2.27, 95 percent confidence interval: 1.25, 3.80).
It is possible that the acculturation level affects Hispanic men and women in the San Luis Valley differently. In the SLVHAS, acculturation was negatively correlated with age and positively correlated with education in Hispanic men and women, but negatively correlated with the CES-D score only in Hispanic women (Spearman's correlation coefficients: -0.005 in men (p = 0.94) and -0.115 in women (p = 0.03)). This may be related to a smaller amount of variability in CES-D scores among the men, a difference in the validity of the CES-D in the men, or a gender difference in the influence of acculturation level on depressive symptoms. Acculturation has been associated with depressive symptoms in studies of Hispanic adults (2, 14
, 16
, 18
). Most reported more depressive symptoms in persons with lower acculturation levels, and some reported that acculturation interacted with gender or factors such as country of birth or recency of immigration. Since fewer than 5 percent of all participants in the SLVHAS reported that their parents were born outside the United States, the acculturation experience in the San Luis Valley might differ from that of recent immigrants. However, the variation in acculturation scores and the association between acculturation and depressive symptoms in women suggest that it is an important factor in this population.
There may be gender differences in how traditional Hispanic cultural orientation affects psychological well-being in older age. A lifelong role for women is to provide caretaking for multiple generations of the family (35, 36
). Providing care for others has been associated with more depressive symptoms (9
), though fulfilling an important role in life has been associated with less depressive symptoms (37
). Some women may have difficulty providing care as they age, others may experience a loss of the role as families change, or the care provided may become more demanding. These factors could lead to a sense of inadequacy and isolation in less acculturated women, and a lifelong emphasis on sacrifice for the family (35
, 36
) may prevent some women from developing material and emotional resources for coping with aging. For men, the traditional role emphasizes strength and providing for the family (35
). The provider role may continue well into older age, especially in ranching and farming where responsibilities are shared with younger generations. In the home setting, men are usually nurtured throughout their lives and generally are not expected to function as caretakers (36
). The valued characteristic of strength may mean that traditional men are less likely to report depressive symptoms.
There are limitations of this study that must be considered when interpreting the results. First, with cross-sectional data it is not possible to examine the temporal relation between depressive symptoms and the risk factors. Second, a survivorship bias may exist in a cross-sectional study that can only be detected with prospective data. Third, since the CES-D does not establish the duration of depressive symptoms or require specific symptoms for a positive result, it may overestimate the prevalence of depression compared with a clinical diagnosis. Fourth, nonresponders might have reported a different prevalence of depressive symptoms that could have affected the prevalence estimates obtained. Finally, bereavement is an important risk factor for depressive symptoms that was not measured in this study, though it is unlikely that it would have explained the observed ethnic differences unless mortality rates between the two populations were very different. Despite certain limitations, this study contributes useful information on depressive symptoms in an increasingly diverse older population.
The prevalence of depressive symptoms in this older, rural, non-Hispanic White and Hispanic population was relatively low, and acculturation level was associated with depressive symptoms in Hispanic women. Since reported mental health service use was low, depressive symptoms would most likely be detected by primary providers of health care who should be alert to the possibility of subgroups of older persons at higher risk for depression.
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ACKNOWLEDGMENTS |
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The authors are pleased to acknowledge the field staff of the San Luis Valley Health and Aging Study, the assistance of the San Luis Valley Health and Aging Study Community Advisory Board, area senior citizens' centers, area health care providers, Emelin Martinez, and Dr. Robert Wallace of the University of Iowa School of Medicine, who consulted on the design of the study.
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NOTES |
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REFERENCES |
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