HHS Public Access Author manuscript Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. Published in final edited form as: Clin Gerontol. 2015 ; 38(5): 412–427. doi:10.1080/07317115.2015.1067272.
NEW AND EMERGING PROFESSIONALS: Does Race Moderate Social Support and Psychological Distress Among Rural Older Adults? Adriana V. Hyams, MA, Ernest N. Wayde, PhD, Martha R. Crowther, PhD, and Forrest R. Scogin, PhD University of Alabama, Tuscaloosa, Alabama, USA
Author Manuscript
Abstract
Author Manuscript
Greater social support is associated with decreased psychological distress among older adults. Researchers have found racial differences in psychological distress. Might race moderate social support and psychological distress? The authors hypothesized African American collectivistic values could increase the importance of social support. Participants were rural adults aged 60 and older (N = 100). Multiple regression analyses controlled for health, income, education, and sex. Race moderated satisfaction with social support and psychological distress. However, greater satisfaction predicted less psychological distress among Caucasians while it was not associated with African Americans’ distress in this sample. Achieving satisfaction with social support may be particularly important for Caucasians receiving therapy. Interventions may also address strategies to improve physical health, emotional support, and quality of social support, which significantly predicted psychological distress for both groups.
Keywords older adults; psychological distress; race; rural; social support
Author Manuscript
Psychological distress (PD) includes all severities of psychological symptoms (Lincoln, Taylor, Chae, & Chatters, 2010). Different types and severities of symptoms warrant various effective mental health treatments (e.g., therapy, medications), as reported by The National Survey on Drug Use and Health (Substance Abuse and Mental Health Service Administration [SAMHSA], June 26, 2008). It also found 4.5% of adults aged 65 and older suffered from serious PD in one year. Yet only 41.8% of them sought treatment, and 56.8% of these did not think they needed it, while 1.3% refused to seek help even though they felt they needed it. Relatedly, Sorkin, Pham, and Ngo-Metzger (2009) found rates of mental health service utilization were low for older adults in general, but racial/ethnic minorities sought services less than Caucasians, though they were just as likely to report needing services. Thus, many older adults, and especially minorities, experience PD and might benefit from treatment. Mental health professionals may raise mental health utilization rates
Address correspondence to Adriana V. Hyams, MA, Department of Psychology, University of Alabama, Box 870348, Tuscaloosa, AL 35487, USA. [email protected]. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wcli.
Hyams et al.
Page 2
Author Manuscript
by increasing their competence when working with diverse groups. Therefore, research devoted to understanding late-life PD in distinct groups is needed. Most research on late-life PD in African Americans compares them to Caucasians so that differences can be studied, potentially leading to clinical practice sensitive to race (Lincoln et al., 2010). Admittedly, this approach has flaws because there are differences within racial groups, and generalizations to every member of a group will not be accurate. However, we believe increasing understanding about racial differences outweighs the disadvantages. For example, we think it is important to consider that risk factors known to trigger PD (e.g., education, income, medical illness, and social support (SS)) are frequently overrepresented in African Americans (Lincoln et al., 2010; Sorkin et al., 2009; Sriwattanakomen, et al., 2010). Thus, we will focus on them in our analyses.
Author Manuscript Author Manuscript
First, we will address education, income, and health. Some researchers have found serious PD is less common in those with higher education and income (Goulia et al., 2012; SAMHSA, June 26, 2008). Older African Americans tend to have lower socioeconomic status (SES) (Lincoln et al., 2010), so they are at greater risk for PD. Regarding health, death rates for chronic illnesses are much higher in African Americans than in Caucasians. Chronic illness and poor self-rated health has been associated with greater PD among African Americans (Goulia et al., 2012; Hu, 2007). Some posit negative affect leads to suboptimal care of one’s health, which worsens mental and physical health further (Hu & Gruber, 2008). Thus, health may affect PD, and if African Americans are at greater risk for medical comorbidity, then their mental health is at risk as well. Social values may distinguish PD in African Americans from Caucasians. Not all members of a racial/ethnic group share the same values; there are individual differences. However, the research that follows demonstrated African Americans may have a greater propensity for collectivism than Caucasians. Abdullah and Brown (2011) reported African Americans tend to highly value mutual reliance, unlike Caucasians, who tend to value individualism. Likewise, African Americans generally consider others in their racial/ethnic group, unrelated by blood, as family and feel a sense of filial responsibility to them and to their extended families. Further, extended families provide much SS, especially for those of lower socioeconomic status (SES), who rely on and visit them more. In fact, 40% of African Americans live in multi-generation homes. In contrast, the nuclear family tends to be emphasized among Caucasians; only 20% live in multi-generation homes (Gallant, Spitze, & Grove, 2010; Gerstel, 2011). Thus, SS may be quite central to African Americans and may mitigate PD.
Author Manuscript
African American values seemed to influence the relation between SS and emotional wellbeing in a study of African American and Caucasian family caregivers. Both races were less distressed while receiving more SS from family and health professionals, but when both races had similarly poor relationships with health professionals, Caucasians were significantly more distressed. When both groups had poor family relationships, on the other hand, African Americans had significantly worse depressed mood. The authors argued this result was not just due to African Americans’ mistrust of medical professionals but also to their emphasis on extended kin and their families’ greater involvement in care recipients’ health care decision-making (Francis, Bowman, Kypriotakis, & Rose, 2011). Caucasians seem more likely to value their medical professionals’ input and to believe they will make
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 3
Author Manuscript
the best decisions for them, whereas African Americans seem to count on their families’ shared values. When African Americans experience PD, the people most likely to assist them in coping may be extended kin. SS seems especially useful to African Americans in rural areas. Fewer resources and social isolation have predisposed them to poorer health. However, Black, Cook, Murry, and Cutrona (2005) found rural African Americans with more SS had greater mental and physical health. SS appears important to rural older adults at risk for PD.
Author Manuscript
Given the evidence SS mitigated PD, perhaps meaningful SS is particularly important. Meaningful SS includes quality SS, emotional support, and satisfaction with SS. Rather than large groups of unsupportive, undependable people, quality SS is meaningful. Emotional support refers to the people one is close to, who will listen, and with whom one can confide and depend upon. Having emotional support often leads to satisfaction with SS (Bosworth, McQuoid, George, & Steffens, 2002; Hays et al., 1998). However, satisfaction with SS is unique because it is a subjective evaluation. People may point to ways they objectively have meaningful SS but remain unsatisfied and want it to be even better. African Americans may benefit more from meaningful SS, considering their propensity for mutual reliance. Few studies have examined meaningful SS variables among African Americans, but they have found favorable outcomes. Emotional support, better quality relationships with friends, and greater satisfaction with SS were significantly associated with better mental health (Bloor, Sandler, Martin, Uchino, & Kinney, 2006; Dressler, 1985; Warren-Findlow, Laditka, Laditka, & Thompson, 2011). One study comparing African Americans to Caucasians found the former needed emotional support more than the latter (Bloor et al., 2006). Thus, meaningful SS may make an important difference to African Americans’ mental health.
Author Manuscript Author Manuscript
The literature reviewed suggested SS may indeed influence PD, but more research is necessary to determine if meaningful SS differentially affects African Americans. As such, we modeled our study on one by Kubzansky, Berkman, and Seeman (2000) that assessed high functioning (i.e., no disability, good health and cognition) older African Americans and Caucasians to test the relation between race and PD. They included SES and SS variables but found no interaction between race and SS on PD. However, their subjects were in much better health than our sample, which is medically-compromised, frail, and rural, offering a different set of circumstances that may result in distinct outcomes. Although they did a second analysis on a lower-functioning sample, it had a very small sample size. Our analysis uses a larger sample of lower-functioning subjects. Also, Kubzansky et al. did a mediation analysis, using SS as mediator between race and PD. Mediation analyses are most appropriate when the relation between two variables is strongly established (Frazier, Tix, & Barron, 2004). As discussed, the relation between PD and race is not well understood (Lincoln et al., 2010; Sorkin et al., 2009). That may explain their lack of findings. We propose SS acts as a greater buffer for PD among African Americans than Caucasians, so using race as a moderator is more appropriate, because moderators show whether a construct differentially affects groups. Moreover, moderation analyses have the most power when the relation between the predictor and outcome are well established (Frazier et al., 2004), as is
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 4
Author Manuscript
the relation between SS and PD (Bloor et al., 2006; Bosworth et al., 2002; Hays et al., 1998; Warren-Findlow et al., 2011). Our study focuses on the relation between PD and emotional support, satisfaction with SS, or quality SS in a sample of rural African Americans and Caucasians. It controls for health, income, and education, which the literature has shown to have an effect on PD, and which is important for this frail, rural sample. Additionally, sex is a covariate because relationships may be more important to females than males (Antonucci & Akiyama, 1987; Bloor et al., 2006; Lindsey, Joe, & Nebbitt, 2010; Trask-Tate et al., 2010). Thus, females may experience greater access to and benefit from SS than males, affecting PD levels.
Author Manuscript
Our first hypothesis is the covariates (i.e., health, income, education, and sex) will account for a significant portion of the variance in PD. Our second hypothesis is race will act as a moderator between PD and emotional support, satisfaction with SS, or quality SS. Practically speaking, this model would suggest older African Americans with less emotional support, satisfaction with SS, or quality SS will have more severe PD than older Caucasians with less of each type, and older African Americans with more of each type will have less severe PD than older Caucasians with more of each type. If results show each type has more impact on African American PD than Caucasian PD, then understanding of PD in this racial group will be enhanced and potentially lead to improved treatments that consider meaningful SS, race, health status, SES, and sex in case conceptualizations.
Method Design
Author Manuscript
We analyzed data from the Project to Enhance Aged Rural Living (PEARL), an efficacy study of home-delivered cognitive-behavioral therapy (CBT) for African American and Caucasian older adults living in rural Alabama. It was approved by The University of Alabama Institutional Review Board. Detailed information about the methods can be found elsewhere (Scogin et al., 2007). In brief, participants endorsed PD and at least one medical condition from among seven common conditions to participate. On average, they endorsed three, making this a medically-compromised sample. Participants were randomized into CBT or minimal support control groups. Five African American and Caucasian social workers conducted CBT for 16–20 sessions per participant, which took an average of five months. Three months post-intervention, they were re-assessed (Scogin et al., 2007). We only used baseline data for this analysis. Participants and Procedures
Author Manuscript
Participants (N = 100; 64 African Americans and 36 Caucasians) were 60 and older in rural areas surrounding Tuscaloosa and Montgomery, AL. Inclusion criteria included a T score of greater than 36 on the Global Severity Index (GSI) of the SCL-90R. Exclusion criteria were a history of schizophrenia, bipolar disorder, or current substance abuse; current treatment with psychotherapy; or apparent cognitive impairment, evidenced by an MMSE score < 24 (Scogin et al., 2007). We eliminated participants with incomplete data in analyses, which accounts for any deviation in sample size. We used the G*Power computer program to
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 5
Author Manuscript
determine a sample size of 100 provided power of .80 to achieve a moderate effect size of 0.10, with α = .05, for two tested predictors and six total predictors (Faul, Erdfelder, Lang, & Buchner, 2007). Measures
Author Manuscript
Psychological distress—PD was measured with the Global Severity Index (GSI) total score of the Symptom Checklist-90-Revised (SCL-90R), an inventory of 90 psychological symptoms that characterize somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, or psychoticism. Participants rate the severity of each symptom for the last week on a scale from 0 (not at all) to 4 (extremely). The GSI measures overall symptom distress (Derogatis, 1983). We compared GSI scores to norms for nonpatient adults. Cronbach’s α = .96 for the 90 items at baseline (Scogin et al., 2007). Researchers have demonstrated the GSI is a valid measure of general PD (Berghout & Zevalkink, 2008; Hafkenscheid, 1993).
Author Manuscript
Social support—When choosing 23 items used in prior research to effectively measure SS, we drew from various sources, including Resources for Enhancing Alzheimer’s Caregiver Health I (REACH) (Krause & Markides, 1990; Lubben, 1988; Sun, Hilgeman, Durkin, Allen, & Burgio, 2009). Questions include such topics as number of close friends; availability of people who can help make important decisions; and satisfaction with friends, neighbors, or family members in the last month. We combined questions whose content described the literature’s accepted definition of each type of SS (i.e., satisfaction, quality, and emotional) and summed them into total scores for each type. We counted some questions multiple times if they overlapped into multiple types (e.g., We included satisfaction with help received in both the satisfaction total and the quality total,). We calculated the reliability for each SS subscale. Quality of SS’s Cronbach α = .79, which was good (Pallant, 2007). For the subscales that consisted of fewer than ten questions, we reported mean inter-item correlations rather than Cronbach α. An ideal range for the mean inter-item correlation is .2-.4 (Pallant, 2007). The mean inter-item correlations were .41 for satisfaction and .25 for emotional support. Demographics—We obtained race, age, sex, income, and education through self-report. We measured self-rated health by asking “In general, would you say your health is …?” Participants selected one of the following options: poor, fair, good, very good, excellent. Data Analysis
Author Manuscript
Using SPSS version 20, we ran descriptive statistics or frequencies, split by race, for age, sex, income, education, health, total SS scores (by type), and GSI totals (see Table 1). We conducted hierarchical multiple regressions by entering the covariates in the first step, followed by the main effects of race and type of SS in the second step. We entered the interaction term (created with standardized race and type of SS variables to prevent multicollinearity with the predictor variables) on the third step.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 6
Author Manuscript
Results There were no significant differences between African Americans and Caucasians on age, sex, income, total satisfaction with SS, total emotional support, quality of support, or level of PD. However, African Americans (M = 2.19, SD = 1.03) reported significantly better physical health than Caucasians (M = 1.53, SD = 0.65); t(97) = 3.48, p < .01 (two-tailed). In contrast, Caucasians had significantly more years of education than African Americans, t(98) = −3.54, p < .01 (two-tailed) (see Table 1).
Author Manuscript
The overall model of the analysis of satisfaction with SS (N = 92) was significant, R2 = .22, F(7, 84) = 3.30, p < .05. Race significantly moderated the relation between satisfaction with SS and PD (see Table 2). Figure 1 shows the nature of the moderation; Caucasians who were more satisfied with their SS experienced less PD, while African Americans remained at about the same level of PD, regardless of their satisfaction. The first model of the analysis of quality of SS (N = 90) showed the covariates (i.e., sex, income, education, self-rated health) accounted for 10.7% of the variance in PD, F(4, 85) = 2.54, p < .05. Adding race and quality of SS to the model accounted for an additional, significant 7.0% of the variance, F(6, 83) = 2.98, p < .05. The interaction of race and quality of SS did not account for a significant additional portion of the variance, so it was dropped from the model. The final, second model demonstrated quality of SS was the only significant predictor of PD; as it decreased, PD increased (see Table 3).
Author Manuscript
The first model of the analysis of emotional support (N = 94) showed the covariates (i.e., sex, income, education, self-rated health) accounted for 13.8% of the variance in PD, F(4, 89) = 3.55, p < .05. Adding race and emotional support to the model accounted for an additional, significant 6.9% of the variance, F(6, 87) = 3.77, p < .01. The interaction of race and emotional support did not account for a significant additional portion of the variance, so it was dropped from the model. The final, second model demonstrated self-rated health and emotional support significantly predicted PD, suggesting poorer self-rated health and less emotional support predicted greater PD (see Table 4).
Discussion
Author Manuscript
Racial differences emerged when analyzing satisfaction with SS but not as hypothesized. Caucasians experienced decreased PD when they were more satisfied with their SS, whereas African Americans’ PD did not seem to be influenced by their satisfaction. Bloor et al. (2006) and Jesse and Swanson (2007) found similar results. The former showed satisfaction with emotional support was moderated by race and predicted better mental health, with Caucasians benefitting more than African Americans. Satisfaction was even more important for those with less education, which described the present sample. Jesse and Swanson found Caucasians with less SS were at significantly greater risk for depression than African Americans. Nevertheless, SS was considered important to African Americans and was associated with risk for depression. One possible reason for the pattern with Caucasians may be that they tend to be less community-oriented (Abdullah & Brown, 2011; Gallant et al., 2010; Gerstel, 2011), so any
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 7
Author Manuscript
perceived improvement in SS may seem much more special and influential. Case in point, Gerstel (2011) noted Caucasians were more likely to offer financial assistance to others than SS. Likewise, Francis et al. (2011) demonstrated Caucasians seemed to be at a loss about health care decision-making without good medical professionals because they were less likely to have significant others they could go to for support. In contrast, a perceived increase in SS seen by African Americans may be less impactful, as African Americans may be accustomed to receiving SS on a more frequent basis. Other studies support this notion (Abdullah & Brown, 2011; Gallant et al., 2010; Gerstel, 2011). It is also possible they were not affected by their satisfaction with SS because they were not highly distressed. Perhaps African Americans will show a benefit only when they need it more and have greater room for improvement. Nevertheless, African Americans’ PD levels were not significantly different from Caucasians, so the difference in groups remains interesting.
Author Manuscript
Another explanation for the results may involve religion. Studies have shown African Americans are a highly religious group in the U.S., sometimes more so than Caucasians, and those residing in rural areas may be even more religious than those residing in urban areas (Holt et al., 2009; Kubzansky et al., 2000). The current sample was rural and Southern, suggesting religion may be salient for this group. It may be an older African American sample from less religious regions of the U.S. would result in SS having a greater impact on satisfaction than the current sample. Peek and O’Neill (2001) and Holt et al. (2009), provided support for this explanation. They speculated religion may have a mediating effect on SS and physical/mental health among African Americans. Therefore, the relation between satisfaction with SS and PD may be weak for the African Americans in this sample and require religion to mediate significant effects (Frazier et al., 2004). Unfortunately, we did not collect data on religion, so this theory cannot be tested.
Author Manuscript
Another finding was better quality SS predicted less PD, but race was not a moderator. Thus, the hypotheses were not supported. This result mirrors others in the literature (WarrenFindlow et al., 2011). Antonucci and Akiyama (1987) found males benefited more from quality of SS than quantity. They were likely to rely on their spouse as their predominant source of SS, so the strength of that relationship was vital to their well-being. The quantity and frequency of support is less important than how good and supportive relationships are.
Author Manuscript
Finally, poorer emotional support predicted increased PD, though race was not a moderator, so the second hypothesis was not supported. This effect has been supported in the literature (Bloor et al., 2006; Kubzansky et al., 2000). However, one study found African Americans reported needing more emotional support than Caucasian participants in suburban and rural areas of North Carolina, though this was not the case among less educated African Americans. The authors suggested African Americans of lower SES may be assisting others of equivalent SES and are overwhelmed by their responsibilities, cancelling out the benefits of the emotional support they receive. Or, they may have greater need for instrumental support (e.g., help with household chores, providing transportation) than emotional support (Bloor et al., 2006). The current sample was of lower SES, which may explain the lack of racial differences, as both Caucasians and African Americans may feel overburdened by others in their social network or may desire more instrumental support than they are receiving. As previously mentioned, it is also possible religion may mediate the relation
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 8
Author Manuscript
between emotional support and PD, which if measured, might have shown evidence for racial differences. For example, emotionally-closer church communities have demonstrated better health, especially among older African Americans (Levin, Chatters, & Taylor, 2005). Pastors and church members have often provided emotional support to African Americans (Holt et al., 2009). One study showed older African Americans gave and received more emotional support to/from their fellow church members than Caucasians (Hayward & Krause, 2013). Further research is necessary to understand religion and emotional support in older African Americans.
Author Manuscript
Poorer self-rated health also predicted greater PD in the emotional support model, which partially supported the first hypothesis that covariates would account for a significant portion of the variance in PD. Other studies have found similar results (Hu, 2007; Hu & Gruber, 2008; Warren-Findlow et al., 2011). For example, older adults with chronic illness have been shown to experience depressive and somatic symptoms. As 80% of older adults have a chronic illness (Conway et al., 2010) this finding indicates a crucial aspect of older adult physical functioning that can have a significant effect on mental health and should be considered in any intervention.
Author Manuscript
Meaningful SS (i.e., satisfaction, quality, and emotional support) may have been especially valuable in this sample of rural older adults, as SS has been a buffer for people who live in secluded areas with few resources (Black et al., 2005). Merely having SS does not seem to auger good mental health; it is the quality of SS that makes the difference. Race did moderate the relation between satisfaction with SS and PD in this sample, though it did not affect African Americans as expected. Reasons for this result may include religion, differences in expectations between groups, and low distress levels. Although race did not change SS’s effect on PD in any other analyses, community is clearly important to the lives of African Americans.
Author Manuscript
Interventions for PD may be best designed by focusing on improving emotional support and quality SS across the board and maintaining good physical health. Regarding satisfaction with SS, these results suggest that for rural, frail, Southern Caucasians, exploring whether or not they are satisfied and what would make them satisfied would be useful. If they are not satisfied, helping them build skills to change their interactions (e.g., communication strategies) so that they encourage the support they want may maximize their ability to accumulate meaningful SS. Interventions for PD among African Americans may be most efficacious if delivered and promoted within a religious setting and with religious officials’ support and understanding. Educating church figures about mental health and treatments may be a central strategy for integrating SS into a plan to improve the physical and mental health of the community. Although religion may be helpful for African Americans, one of these analyses’ limitations was that it used secondary data, which was not designed specifically for these research questions. Therefore, religion can only be speculated as potentially helpful because no religious data was collected. Additionally, this was not a highly distressed sample, so it may be more significant effects would have been found if there had been more room for improvement.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 9
Author Manuscript
Future studies might use qualitative methods to understand SS’s and religion’s function for these two groups. Questions might include, “What are your sources of SS? How available are they to you? How does SS help you? What specific qualities of your SS make a difference? How does religion help you? What does it do for you in terms of emotional health?
Author Manuscript
Future research might also compare African Americans and Caucasians who are dissatisfied with their support systems with those who are satisfied with them. Racial differences may emerge showing dissatisfied African Americans have worse PD than dissatisfied Caucasians, because African Americans may feel let down by the lack of a support system they may normally expect. Such results may suggest it is when group norms for SS are not maintained that racial differences emerge, African Americans experiencing worse mental health and Caucasians experiencing better mental health. Such information may assist mental health professionals in assessing African Americans’ dissatisfaction with their support system and targeting it as a goal for intervention.
References
Author Manuscript Author Manuscript
Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clinical Psychology Review. 2011; 31:934–948. [PubMed: 21683671] Antonucci TC, Akiyama H. An examination of sex differences in social support among older men and women. Sex Roles. 1987; 17(11/12):737–749. Berghout CC, Zevalkink J. Identifying clinical cases among patients assigned to psychoanalytic treatment. Bulletin of the Menninger Clinic. 2008; 72(3):163–178. [PubMed: 18990053] Black AR, Cook JL, Murry VM, Cutrona CE. Ties that bind: Implications of social support for rural, partnered African American women’s health functioning. Women’s Health Issues. 2005; 15:216– 223. [PubMed: 16165007] Bloor LE, Sandler RS, Martin C, Uchino BN, Kinney AY. Associations between emotional support and health-related quality of life among a population-based sample of Blacks and Whites. Journal of Social and Clinical Psychology. 2006; 25(1):96–116. Bosworth HB, McQuoid DR, George LK, Steffens DC. Time-to-remission from geriatric depression: Psychosocial and clinical factors. American Journal of Geriatric Psychiatry. 2002; 10(5):551–559. [PubMed: 12213689] Conway F, Magai C, McPherson-Salandy R, Milano K. Synergy between molecular and contextual views of coping among four ethnic groups of older adults. The International Journal of Aging & Human Development. 2010; 70(4):319–343. [PubMed: 20649162] Derogatis, LR. SCL-90R administration, scoring and procedures manual – II for the R(evised) version. Towson, MD: Clinical Psychometric Research; 1983. Dressler WW. Extended family relationships, social support, and mental health in a Southern Black Community. Journal of Health and Social Behavior. 1985; 26(1):39–48. [PubMed: 3998433] Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007; 39:175– 191. [PubMed: 17695343] Francis LE, Bowman KF, Kypriotakis G, Rose JH. Relationships and emotional wellbeing among African American and White advanced cancer caregivers. Patient Education and Counseling. 2011; 85(3):446–453. [PubMed: 21439755] Frazier PA, Tix AP, Barron KE. Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology. 2004; 51(1):115–134. Gallant MP, Spitze G, Grove JG. Chronic illness self-care and the family lives of older adults: A synthetic review across four ethnic groups. Journal of Cross Cultural Gerontology. 2010; 25:21– 43. [PubMed: 20177963]
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 10
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gerstel N. Rethinking families and community: The color, class, and centrality of extended kin ties. Sociological Forum. 2011; 26(1):1–20. Goulia P, Papadimitriou I, Machado MO, Mantas C, Pappa C, Tsianos E, Hyphantis T. Does psychological distress vary between younger and older adults in health and disease? Journal of Psychosomatic Research. 2012; 72(2):120–128. [PubMed: 22281453] Hafkenscheid A. Psychometric evaluation of the symptom checklist (SCL-90) in psychiatric inpatients. Personality and Individual Differences. 1993; 14(6):751–756. Hays JC, Landerman LR, George LK, Flint EP, Koenig HG, Land KC, Blazer DG. Social correlates of the dimensions of depression in the elderly. Journal of Gerontology: Psychological Sciences. 1998; 53B(1):31–39. Hayward DR, Krause N. Changes in church-based social support relationships during older adulthood. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences. 2013; 68B: 85–96. Holt CL, Schulz E, Wynn TA. Perceptions of the religion--health connection among African Americans in the Southeastern United States: Sex, age, and urban/rural differences. Health Education and Behavior. 2009; 36:62–80. [PubMed: 17652617] Hu J. Health-related quality of life in low-income older African Americans. Journal of Community Health Nursing. 2007; 24(4):253–265. [PubMed: 18092917] Hu J, Gruber KJ. Positive and negative affect and health functioning indicators among older adults with chronic illnesses. Issues in Mental Health Nursing. 2008; 29:895–911. [PubMed: 18649214] Jesse DE, Swanson MS. Risks and resources associated with antepartum risk for depression among rural southern women. Nursing Research. 2007; 56(6):378–386. [PubMed: 18004184] Krause N, Markides K. Measuring social support among older adults. International Journal of Aging and Human Development. 1990; 30(1):37–53. [PubMed: 2407665] Kubzansky LD, Berkman LF, Seeman TE. Social conditions and distress in elderly persons: Findings from the MacArthur studies of successful aging. Journal of Gerontology: Psychological Sciences. 2000; 55B(4):238–246. Levin J, Chatters LM, Taylor RJ. Religion, health and medicine in African-Americans: Implications for physicians. Journal of the National Medical Association. 2005; 97:237–249. [PubMed: 15712787] Lincoln KD, Taylor RJ, Chae DH, Chatters LM. Demographic correlates of psychological well-being and distress among older African Americans and Caribbean Black adults. Best Practices in Mental Health: An International Journal. 2010; 6(1):103–126. Lindsey MA, Joe S, Nebbitt V. Family matters: The role of mental health stigma and social support on depressive symptoms and subsequent help seeking among African American boys. Journal of Black Psychology. 2010; 36(4):458–482. [PubMed: 20953336] Lubben JE. Assessing social networks among elderly populations. Family & Community Health: The Journal of Health Promotion & Maintenance. 1988; 11(3):42–52. Pallant, J. SPSS survival manual: A step by step guide to data analysis using SPSS for Windows. 3rd. London: McGraw Hill Open University Press; 2007. Peek MK, O'Neill GS. Networks in later life: An examination of race differences in social support networks. The International Journal of Aging & Human Development. 2001; 52(3):207–229. [PubMed: 11407487] Scogin F, Morthland M, Kaufman A, Burgio L, Chaplin W, Kong G. Improving quality of life in diverse rural older adults: A randomized trial of a psychological treatment. Psychology and Aging. 2007; 22(4):657–665. [PubMed: 18179286] Sorkin DH, Pham E, Ngo-Metzger Q. Racial and ethnic differences in the mental health needs and access to care of older adults in California. Journal of the American Geriatrics Society. 2009; 57(12):2311–2317. [PubMed: 19943830] Sriwattanakomen R, McPherron J, Chatman J, Morse JQ, Martire LM, Karp JF, Reynolds CF III. A comparison of the frequencies of risk factors for depression in older black and white participants in a study of indicated prevention. International Psychogeriatrics. 2010; 22(8):1240–1247. [PubMed: 20843391]
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 11
Author Manuscript
Substance Abuse and Mental Health Services Administration. National Survey of Drug Use and Health Report: Serious psychological distress among adults aged 50 or older: 2005 and 2006. Office of Applied Studies, Substance Abuse and Mental Health Services Administration; 2008b Jun 26. Sun F, Hilgeman MM, Durkin DW, Allen RS, Burgio LD. Perceived income inadequacy as a predictor of psychological distress in Alzheimer's caregivers. Psychology and Aging. 2009; 24(1):177–183. [PubMed: 19290749] Trask-Tate A, Cunningham M, Lang-DeGrange L. The importance of family: The impact of social support on symptoms of psychological distress in African American girls. Research in Human Development. 2010; 7(3):164–182. Warren-Findlow J, Laditka JN, Laditka SB, Thompson ME. Associations between social relationships and emotional well-being in middle-aged and older African Americans. Research on Aging. 2011; 33(6):713–734.
Author Manuscript Author Manuscript Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 12
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
FIGURE 1.
Interaction of satisfaction with social support and race on psychological distress.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 13
Table 1
Author Manuscript
Descriptive Characteristics of the Sample African American (n = 64) Characteristic
M (SD) or %
Age
76.23 (7.61)
Caucasian (n = 36)
95% CI
M (SD) or %
95% CI
[74.33, 78.14]
76.17 (6.54)
[73.95, 78.38]
Sex Male
21.9%
Female
78.1%
Incomea
0.95 (2.42)
22.2% 77.8% [0.33, 1.57]
1.11 (1.95)
[0.45, 1.77]
Health
Author Manuscript
Poor
25.4%
55.6%
Fair
46.0%
36.1%
Good
15.9%
8.3%
Very Good
9.5%
0%
Excellent
3.2%
0%
Education (in years)
7.81 (4.01)
[6.81, 8.81]
10.58 (3.26)
[9.48, 11.68]
Total satisfaction with social support
8.40 (2.68)
[7.71, 9.09]
7.51(2.84)
[6.54, 8.49]
Total emotional support
13.35 (4.72)
[12.16, 14.55]
12.51 (5.41)
[10.65, 14.37]
Quality of social support
24.63 (7.73)
[22.61, 26.64]
22.68 (8.35)
[19.76, 25.59]
Total GSI scores
58.22 (8.02)
[56.22, 60.22]
60.81 (10.28)
[57.33, 64.28]
Note. CI = confidence interval. GSI = Global Severity Index. a
The mean income for African Americans and Caucasians lies somewhere between $5,000 and $9,999.
Author Manuscript Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. −1.68 −0.66 −0.80
Self-rated Health
Race
Satisfaction
0.33 −1.75 −0.73 −0.77 −2.08
Self-rated Health
Race
Satisfaction
Interaction (Race × Satisfaction)
0.22
Income
Education
−4.50
Sex
p < .05
*
0.35
Education
.05*
0.19
Income
Step 3
−4.00
Sex
Step 2
.06*
0.35
Education −1.94
0.20
Income
Self-rated Health
−3.91
.10
Step 1
B
Sex
ΔR2
Predictor
[−3.82, −0.35]
[−1.39, −0.15]
[−4.66, 3.20]
[−3.70, 0.20]
[−0.13, 0.78]
[−0.54, 0.99]
[−8.67, −0.34]
[−1.44, −0.16]
[−4.69, 3.38]
[−3.68, 0.33]
[−0.11, 0.82]
[−0.59, 0.98]
[−8.26, 0.26]
[−3.86, −0.03]
[−0.10, 0.80]
[−0.60, 1.00]
[−8.26, 0.44]
95% CI
0.87
0.31
1.98
0.98
0.23
0.38
2.09
0.32
2.03
1.01
0.23
0.39
2.14
0.96
0.23
0.40
2.19
SE
−.23*
−.24*
−.04
−.19
.15
.06
−.21*
−.25*
−.04
−.18
.16
.05
−.19
−.21*
.16
.05
−.18
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Total Satisfaction with Social Support
Author Manuscript
Table 2 Hyams et al. Page 14
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. 0.33 −1.94 −0.41 −0.28 −1.54
Self-rated Health
Race
Quality social support
Interaction (Race × Quality support)
0.33
Income
Education
−4.13
Sex
p < .01
**
p < .05,
*
−0.30
Quality social support .03
−0.61
Race
Step 3
0.35 −1.87
Self-rated Health
0.22
Income
Education
−3.56
Sex
Step 2
.07*
0.34
Education −2.05
0.32
Income
Self-rated Health
−3.78
.11*
Step 1
B
Sex
ΔR2
Predictor
[−3.27, 0.19]
[−0.50, −0.06]
[−4.44, 3.62]
[−3.93, 0.05]
[−0.13, 0.80]
[−0.53, 1.18]
[−8.41, 0.14]
[−0.52, −0.08]
[−4.68, 3.47]
[−3.89, 0.14]
[−0.12, 0.82]
[−0.63, 1.07]
[−7.84, 0.71]
[−4.00, −0.11]
[−0.12, 0.80]
[−0.56, 1.19]
[−8.18, 0.62]
95% CI
0.87
0.11
2.03
1.00
0.23
0.43
2.15
0.11
2.05
1.01
0.24
0.43
2.15
0.98
0.23
0.44
2.21
SE
−.18
−.26*
−.02
−.21
.15
.08
−.19
−.27**
−.03
−.20
.16
.05
−.17
−.22*
.15
.08
−.18
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Quality Social Support
Author Manuscript
Table 3 Hyams et al. Page 15
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. −4.38 0.43 0.32 −2.20 −0.12 −0.44 −1.53
Sex
Income
Education
Self-rated Health
Race
Emotional support
Interaction (Race × Emotional support)
p < .01
**
p < .05,
*
−0.48
Emotional support .03
−0.11
Race
Step 3
0.33 −2.14
Self-rated Health
0.30
Income
Education
−3.90
Sex
Step 2
.07*
0.34
Education −2.42
0.39
Income
Self-rated Health
−4.17
.14*
Step 1
B
Sex
ΔR2
Predictor
[−3.16, 0.11]
[−0.79, −0.10]
[−4.10, 3.87]
[−4.12, −0.28]
[−0.14, 0.78]
[−0.42, 1.27]
[−8.53, −0.22]
[−0.83, −0.13]
[−4.15, 3.94]
[−4.09, −0.20]
[−0.13, 0.80]
[−0.55, 1.14]
[−8.07, 0.28]
[−4.29, −0.56]
[−0.12, 0.79]
[−0.47, 1.26]
[−8.47, 0.12]
95% CI
0.82
0.17
2.01
0.97
0.23
0.42
2.09
0.18
2.03
0.98
0.24
0.42
2.10
0.94
0.23
0.44
2.16
SE
−.18
−.24*
−.01
−.23*
.14
.10
−.20*
−.27**
−.01
−.23*
.15
.07
−.18
−.26*
.15
.09
−.19
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Emotional Support
Author Manuscript
Table 4 Hyams et al. Page 16
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. Published in final edited form as: Clin Gerontol. 2015 ; 38(5): 412–427. doi:10.1080/07317115.2015.1067272.
NEW AND EMERGING PROFESSIONALS: Does Race Moderate Social Support and Psychological Distress Among Rural Older Adults? Adriana V. Hyams, MA, Ernest N. Wayde, PhD, Martha R. Crowther, PhD, and Forrest R. Scogin, PhD University of Alabama, Tuscaloosa, Alabama, USA
Author Manuscript
Abstract
Author Manuscript
Greater social support is associated with decreased psychological distress among older adults. Researchers have found racial differences in psychological distress. Might race moderate social support and psychological distress? The authors hypothesized African American collectivistic values could increase the importance of social support. Participants were rural adults aged 60 and older (N = 100). Multiple regression analyses controlled for health, income, education, and sex. Race moderated satisfaction with social support and psychological distress. However, greater satisfaction predicted less psychological distress among Caucasians while it was not associated with African Americans’ distress in this sample. Achieving satisfaction with social support may be particularly important for Caucasians receiving therapy. Interventions may also address strategies to improve physical health, emotional support, and quality of social support, which significantly predicted psychological distress for both groups.
Keywords older adults; psychological distress; race; rural; social support
Author Manuscript
Psychological distress (PD) includes all severities of psychological symptoms (Lincoln, Taylor, Chae, & Chatters, 2010). Different types and severities of symptoms warrant various effective mental health treatments (e.g., therapy, medications), as reported by The National Survey on Drug Use and Health (Substance Abuse and Mental Health Service Administration [SAMHSA], June 26, 2008). It also found 4.5% of adults aged 65 and older suffered from serious PD in one year. Yet only 41.8% of them sought treatment, and 56.8% of these did not think they needed it, while 1.3% refused to seek help even though they felt they needed it. Relatedly, Sorkin, Pham, and Ngo-Metzger (2009) found rates of mental health service utilization were low for older adults in general, but racial/ethnic minorities sought services less than Caucasians, though they were just as likely to report needing services. Thus, many older adults, and especially minorities, experience PD and might benefit from treatment. Mental health professionals may raise mental health utilization rates
Address correspondence to Adriana V. Hyams, MA, Department of Psychology, University of Alabama, Box 870348, Tuscaloosa, AL 35487, USA. [email protected]. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wcli.
Hyams et al.
Page 2
Author Manuscript
by increasing their competence when working with diverse groups. Therefore, research devoted to understanding late-life PD in distinct groups is needed. Most research on late-life PD in African Americans compares them to Caucasians so that differences can be studied, potentially leading to clinical practice sensitive to race (Lincoln et al., 2010). Admittedly, this approach has flaws because there are differences within racial groups, and generalizations to every member of a group will not be accurate. However, we believe increasing understanding about racial differences outweighs the disadvantages. For example, we think it is important to consider that risk factors known to trigger PD (e.g., education, income, medical illness, and social support (SS)) are frequently overrepresented in African Americans (Lincoln et al., 2010; Sorkin et al., 2009; Sriwattanakomen, et al., 2010). Thus, we will focus on them in our analyses.
Author Manuscript Author Manuscript
First, we will address education, income, and health. Some researchers have found serious PD is less common in those with higher education and income (Goulia et al., 2012; SAMHSA, June 26, 2008). Older African Americans tend to have lower socioeconomic status (SES) (Lincoln et al., 2010), so they are at greater risk for PD. Regarding health, death rates for chronic illnesses are much higher in African Americans than in Caucasians. Chronic illness and poor self-rated health has been associated with greater PD among African Americans (Goulia et al., 2012; Hu, 2007). Some posit negative affect leads to suboptimal care of one’s health, which worsens mental and physical health further (Hu & Gruber, 2008). Thus, health may affect PD, and if African Americans are at greater risk for medical comorbidity, then their mental health is at risk as well. Social values may distinguish PD in African Americans from Caucasians. Not all members of a racial/ethnic group share the same values; there are individual differences. However, the research that follows demonstrated African Americans may have a greater propensity for collectivism than Caucasians. Abdullah and Brown (2011) reported African Americans tend to highly value mutual reliance, unlike Caucasians, who tend to value individualism. Likewise, African Americans generally consider others in their racial/ethnic group, unrelated by blood, as family and feel a sense of filial responsibility to them and to their extended families. Further, extended families provide much SS, especially for those of lower socioeconomic status (SES), who rely on and visit them more. In fact, 40% of African Americans live in multi-generation homes. In contrast, the nuclear family tends to be emphasized among Caucasians; only 20% live in multi-generation homes (Gallant, Spitze, & Grove, 2010; Gerstel, 2011). Thus, SS may be quite central to African Americans and may mitigate PD.
Author Manuscript
African American values seemed to influence the relation between SS and emotional wellbeing in a study of African American and Caucasian family caregivers. Both races were less distressed while receiving more SS from family and health professionals, but when both races had similarly poor relationships with health professionals, Caucasians were significantly more distressed. When both groups had poor family relationships, on the other hand, African Americans had significantly worse depressed mood. The authors argued this result was not just due to African Americans’ mistrust of medical professionals but also to their emphasis on extended kin and their families’ greater involvement in care recipients’ health care decision-making (Francis, Bowman, Kypriotakis, & Rose, 2011). Caucasians seem more likely to value their medical professionals’ input and to believe they will make
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 3
Author Manuscript
the best decisions for them, whereas African Americans seem to count on their families’ shared values. When African Americans experience PD, the people most likely to assist them in coping may be extended kin. SS seems especially useful to African Americans in rural areas. Fewer resources and social isolation have predisposed them to poorer health. However, Black, Cook, Murry, and Cutrona (2005) found rural African Americans with more SS had greater mental and physical health. SS appears important to rural older adults at risk for PD.
Author Manuscript
Given the evidence SS mitigated PD, perhaps meaningful SS is particularly important. Meaningful SS includes quality SS, emotional support, and satisfaction with SS. Rather than large groups of unsupportive, undependable people, quality SS is meaningful. Emotional support refers to the people one is close to, who will listen, and with whom one can confide and depend upon. Having emotional support often leads to satisfaction with SS (Bosworth, McQuoid, George, & Steffens, 2002; Hays et al., 1998). However, satisfaction with SS is unique because it is a subjective evaluation. People may point to ways they objectively have meaningful SS but remain unsatisfied and want it to be even better. African Americans may benefit more from meaningful SS, considering their propensity for mutual reliance. Few studies have examined meaningful SS variables among African Americans, but they have found favorable outcomes. Emotional support, better quality relationships with friends, and greater satisfaction with SS were significantly associated with better mental health (Bloor, Sandler, Martin, Uchino, & Kinney, 2006; Dressler, 1985; Warren-Findlow, Laditka, Laditka, & Thompson, 2011). One study comparing African Americans to Caucasians found the former needed emotional support more than the latter (Bloor et al., 2006). Thus, meaningful SS may make an important difference to African Americans’ mental health.
Author Manuscript Author Manuscript
The literature reviewed suggested SS may indeed influence PD, but more research is necessary to determine if meaningful SS differentially affects African Americans. As such, we modeled our study on one by Kubzansky, Berkman, and Seeman (2000) that assessed high functioning (i.e., no disability, good health and cognition) older African Americans and Caucasians to test the relation between race and PD. They included SES and SS variables but found no interaction between race and SS on PD. However, their subjects were in much better health than our sample, which is medically-compromised, frail, and rural, offering a different set of circumstances that may result in distinct outcomes. Although they did a second analysis on a lower-functioning sample, it had a very small sample size. Our analysis uses a larger sample of lower-functioning subjects. Also, Kubzansky et al. did a mediation analysis, using SS as mediator between race and PD. Mediation analyses are most appropriate when the relation between two variables is strongly established (Frazier, Tix, & Barron, 2004). As discussed, the relation between PD and race is not well understood (Lincoln et al., 2010; Sorkin et al., 2009). That may explain their lack of findings. We propose SS acts as a greater buffer for PD among African Americans than Caucasians, so using race as a moderator is more appropriate, because moderators show whether a construct differentially affects groups. Moreover, moderation analyses have the most power when the relation between the predictor and outcome are well established (Frazier et al., 2004), as is
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 4
Author Manuscript
the relation between SS and PD (Bloor et al., 2006; Bosworth et al., 2002; Hays et al., 1998; Warren-Findlow et al., 2011). Our study focuses on the relation between PD and emotional support, satisfaction with SS, or quality SS in a sample of rural African Americans and Caucasians. It controls for health, income, and education, which the literature has shown to have an effect on PD, and which is important for this frail, rural sample. Additionally, sex is a covariate because relationships may be more important to females than males (Antonucci & Akiyama, 1987; Bloor et al., 2006; Lindsey, Joe, & Nebbitt, 2010; Trask-Tate et al., 2010). Thus, females may experience greater access to and benefit from SS than males, affecting PD levels.
Author Manuscript
Our first hypothesis is the covariates (i.e., health, income, education, and sex) will account for a significant portion of the variance in PD. Our second hypothesis is race will act as a moderator between PD and emotional support, satisfaction with SS, or quality SS. Practically speaking, this model would suggest older African Americans with less emotional support, satisfaction with SS, or quality SS will have more severe PD than older Caucasians with less of each type, and older African Americans with more of each type will have less severe PD than older Caucasians with more of each type. If results show each type has more impact on African American PD than Caucasian PD, then understanding of PD in this racial group will be enhanced and potentially lead to improved treatments that consider meaningful SS, race, health status, SES, and sex in case conceptualizations.
Method Design
Author Manuscript
We analyzed data from the Project to Enhance Aged Rural Living (PEARL), an efficacy study of home-delivered cognitive-behavioral therapy (CBT) for African American and Caucasian older adults living in rural Alabama. It was approved by The University of Alabama Institutional Review Board. Detailed information about the methods can be found elsewhere (Scogin et al., 2007). In brief, participants endorsed PD and at least one medical condition from among seven common conditions to participate. On average, they endorsed three, making this a medically-compromised sample. Participants were randomized into CBT or minimal support control groups. Five African American and Caucasian social workers conducted CBT for 16–20 sessions per participant, which took an average of five months. Three months post-intervention, they were re-assessed (Scogin et al., 2007). We only used baseline data for this analysis. Participants and Procedures
Author Manuscript
Participants (N = 100; 64 African Americans and 36 Caucasians) were 60 and older in rural areas surrounding Tuscaloosa and Montgomery, AL. Inclusion criteria included a T score of greater than 36 on the Global Severity Index (GSI) of the SCL-90R. Exclusion criteria were a history of schizophrenia, bipolar disorder, or current substance abuse; current treatment with psychotherapy; or apparent cognitive impairment, evidenced by an MMSE score < 24 (Scogin et al., 2007). We eliminated participants with incomplete data in analyses, which accounts for any deviation in sample size. We used the G*Power computer program to
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 5
Author Manuscript
determine a sample size of 100 provided power of .80 to achieve a moderate effect size of 0.10, with α = .05, for two tested predictors and six total predictors (Faul, Erdfelder, Lang, & Buchner, 2007). Measures
Author Manuscript
Psychological distress—PD was measured with the Global Severity Index (GSI) total score of the Symptom Checklist-90-Revised (SCL-90R), an inventory of 90 psychological symptoms that characterize somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, or psychoticism. Participants rate the severity of each symptom for the last week on a scale from 0 (not at all) to 4 (extremely). The GSI measures overall symptom distress (Derogatis, 1983). We compared GSI scores to norms for nonpatient adults. Cronbach’s α = .96 for the 90 items at baseline (Scogin et al., 2007). Researchers have demonstrated the GSI is a valid measure of general PD (Berghout & Zevalkink, 2008; Hafkenscheid, 1993).
Author Manuscript
Social support—When choosing 23 items used in prior research to effectively measure SS, we drew from various sources, including Resources for Enhancing Alzheimer’s Caregiver Health I (REACH) (Krause & Markides, 1990; Lubben, 1988; Sun, Hilgeman, Durkin, Allen, & Burgio, 2009). Questions include such topics as number of close friends; availability of people who can help make important decisions; and satisfaction with friends, neighbors, or family members in the last month. We combined questions whose content described the literature’s accepted definition of each type of SS (i.e., satisfaction, quality, and emotional) and summed them into total scores for each type. We counted some questions multiple times if they overlapped into multiple types (e.g., We included satisfaction with help received in both the satisfaction total and the quality total,). We calculated the reliability for each SS subscale. Quality of SS’s Cronbach α = .79, which was good (Pallant, 2007). For the subscales that consisted of fewer than ten questions, we reported mean inter-item correlations rather than Cronbach α. An ideal range for the mean inter-item correlation is .2-.4 (Pallant, 2007). The mean inter-item correlations were .41 for satisfaction and .25 for emotional support. Demographics—We obtained race, age, sex, income, and education through self-report. We measured self-rated health by asking “In general, would you say your health is …?” Participants selected one of the following options: poor, fair, good, very good, excellent. Data Analysis
Author Manuscript
Using SPSS version 20, we ran descriptive statistics or frequencies, split by race, for age, sex, income, education, health, total SS scores (by type), and GSI totals (see Table 1). We conducted hierarchical multiple regressions by entering the covariates in the first step, followed by the main effects of race and type of SS in the second step. We entered the interaction term (created with standardized race and type of SS variables to prevent multicollinearity with the predictor variables) on the third step.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 6
Author Manuscript
Results There were no significant differences between African Americans and Caucasians on age, sex, income, total satisfaction with SS, total emotional support, quality of support, or level of PD. However, African Americans (M = 2.19, SD = 1.03) reported significantly better physical health than Caucasians (M = 1.53, SD = 0.65); t(97) = 3.48, p < .01 (two-tailed). In contrast, Caucasians had significantly more years of education than African Americans, t(98) = −3.54, p < .01 (two-tailed) (see Table 1).
Author Manuscript
The overall model of the analysis of satisfaction with SS (N = 92) was significant, R2 = .22, F(7, 84) = 3.30, p < .05. Race significantly moderated the relation between satisfaction with SS and PD (see Table 2). Figure 1 shows the nature of the moderation; Caucasians who were more satisfied with their SS experienced less PD, while African Americans remained at about the same level of PD, regardless of their satisfaction. The first model of the analysis of quality of SS (N = 90) showed the covariates (i.e., sex, income, education, self-rated health) accounted for 10.7% of the variance in PD, F(4, 85) = 2.54, p < .05. Adding race and quality of SS to the model accounted for an additional, significant 7.0% of the variance, F(6, 83) = 2.98, p < .05. The interaction of race and quality of SS did not account for a significant additional portion of the variance, so it was dropped from the model. The final, second model demonstrated quality of SS was the only significant predictor of PD; as it decreased, PD increased (see Table 3).
Author Manuscript
The first model of the analysis of emotional support (N = 94) showed the covariates (i.e., sex, income, education, self-rated health) accounted for 13.8% of the variance in PD, F(4, 89) = 3.55, p < .05. Adding race and emotional support to the model accounted for an additional, significant 6.9% of the variance, F(6, 87) = 3.77, p < .01. The interaction of race and emotional support did not account for a significant additional portion of the variance, so it was dropped from the model. The final, second model demonstrated self-rated health and emotional support significantly predicted PD, suggesting poorer self-rated health and less emotional support predicted greater PD (see Table 4).
Discussion
Author Manuscript
Racial differences emerged when analyzing satisfaction with SS but not as hypothesized. Caucasians experienced decreased PD when they were more satisfied with their SS, whereas African Americans’ PD did not seem to be influenced by their satisfaction. Bloor et al. (2006) and Jesse and Swanson (2007) found similar results. The former showed satisfaction with emotional support was moderated by race and predicted better mental health, with Caucasians benefitting more than African Americans. Satisfaction was even more important for those with less education, which described the present sample. Jesse and Swanson found Caucasians with less SS were at significantly greater risk for depression than African Americans. Nevertheless, SS was considered important to African Americans and was associated with risk for depression. One possible reason for the pattern with Caucasians may be that they tend to be less community-oriented (Abdullah & Brown, 2011; Gallant et al., 2010; Gerstel, 2011), so any
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 7
Author Manuscript
perceived improvement in SS may seem much more special and influential. Case in point, Gerstel (2011) noted Caucasians were more likely to offer financial assistance to others than SS. Likewise, Francis et al. (2011) demonstrated Caucasians seemed to be at a loss about health care decision-making without good medical professionals because they were less likely to have significant others they could go to for support. In contrast, a perceived increase in SS seen by African Americans may be less impactful, as African Americans may be accustomed to receiving SS on a more frequent basis. Other studies support this notion (Abdullah & Brown, 2011; Gallant et al., 2010; Gerstel, 2011). It is also possible they were not affected by their satisfaction with SS because they were not highly distressed. Perhaps African Americans will show a benefit only when they need it more and have greater room for improvement. Nevertheless, African Americans’ PD levels were not significantly different from Caucasians, so the difference in groups remains interesting.
Author Manuscript
Another explanation for the results may involve religion. Studies have shown African Americans are a highly religious group in the U.S., sometimes more so than Caucasians, and those residing in rural areas may be even more religious than those residing in urban areas (Holt et al., 2009; Kubzansky et al., 2000). The current sample was rural and Southern, suggesting religion may be salient for this group. It may be an older African American sample from less religious regions of the U.S. would result in SS having a greater impact on satisfaction than the current sample. Peek and O’Neill (2001) and Holt et al. (2009), provided support for this explanation. They speculated religion may have a mediating effect on SS and physical/mental health among African Americans. Therefore, the relation between satisfaction with SS and PD may be weak for the African Americans in this sample and require religion to mediate significant effects (Frazier et al., 2004). Unfortunately, we did not collect data on religion, so this theory cannot be tested.
Author Manuscript
Another finding was better quality SS predicted less PD, but race was not a moderator. Thus, the hypotheses were not supported. This result mirrors others in the literature (WarrenFindlow et al., 2011). Antonucci and Akiyama (1987) found males benefited more from quality of SS than quantity. They were likely to rely on their spouse as their predominant source of SS, so the strength of that relationship was vital to their well-being. The quantity and frequency of support is less important than how good and supportive relationships are.
Author Manuscript
Finally, poorer emotional support predicted increased PD, though race was not a moderator, so the second hypothesis was not supported. This effect has been supported in the literature (Bloor et al., 2006; Kubzansky et al., 2000). However, one study found African Americans reported needing more emotional support than Caucasian participants in suburban and rural areas of North Carolina, though this was not the case among less educated African Americans. The authors suggested African Americans of lower SES may be assisting others of equivalent SES and are overwhelmed by their responsibilities, cancelling out the benefits of the emotional support they receive. Or, they may have greater need for instrumental support (e.g., help with household chores, providing transportation) than emotional support (Bloor et al., 2006). The current sample was of lower SES, which may explain the lack of racial differences, as both Caucasians and African Americans may feel overburdened by others in their social network or may desire more instrumental support than they are receiving. As previously mentioned, it is also possible religion may mediate the relation
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 8
Author Manuscript
between emotional support and PD, which if measured, might have shown evidence for racial differences. For example, emotionally-closer church communities have demonstrated better health, especially among older African Americans (Levin, Chatters, & Taylor, 2005). Pastors and church members have often provided emotional support to African Americans (Holt et al., 2009). One study showed older African Americans gave and received more emotional support to/from their fellow church members than Caucasians (Hayward & Krause, 2013). Further research is necessary to understand religion and emotional support in older African Americans.
Author Manuscript
Poorer self-rated health also predicted greater PD in the emotional support model, which partially supported the first hypothesis that covariates would account for a significant portion of the variance in PD. Other studies have found similar results (Hu, 2007; Hu & Gruber, 2008; Warren-Findlow et al., 2011). For example, older adults with chronic illness have been shown to experience depressive and somatic symptoms. As 80% of older adults have a chronic illness (Conway et al., 2010) this finding indicates a crucial aspect of older adult physical functioning that can have a significant effect on mental health and should be considered in any intervention.
Author Manuscript
Meaningful SS (i.e., satisfaction, quality, and emotional support) may have been especially valuable in this sample of rural older adults, as SS has been a buffer for people who live in secluded areas with few resources (Black et al., 2005). Merely having SS does not seem to auger good mental health; it is the quality of SS that makes the difference. Race did moderate the relation between satisfaction with SS and PD in this sample, though it did not affect African Americans as expected. Reasons for this result may include religion, differences in expectations between groups, and low distress levels. Although race did not change SS’s effect on PD in any other analyses, community is clearly important to the lives of African Americans.
Author Manuscript
Interventions for PD may be best designed by focusing on improving emotional support and quality SS across the board and maintaining good physical health. Regarding satisfaction with SS, these results suggest that for rural, frail, Southern Caucasians, exploring whether or not they are satisfied and what would make them satisfied would be useful. If they are not satisfied, helping them build skills to change their interactions (e.g., communication strategies) so that they encourage the support they want may maximize their ability to accumulate meaningful SS. Interventions for PD among African Americans may be most efficacious if delivered and promoted within a religious setting and with religious officials’ support and understanding. Educating church figures about mental health and treatments may be a central strategy for integrating SS into a plan to improve the physical and mental health of the community. Although religion may be helpful for African Americans, one of these analyses’ limitations was that it used secondary data, which was not designed specifically for these research questions. Therefore, religion can only be speculated as potentially helpful because no religious data was collected. Additionally, this was not a highly distressed sample, so it may be more significant effects would have been found if there had been more room for improvement.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 9
Author Manuscript
Future studies might use qualitative methods to understand SS’s and religion’s function for these two groups. Questions might include, “What are your sources of SS? How available are they to you? How does SS help you? What specific qualities of your SS make a difference? How does religion help you? What does it do for you in terms of emotional health?
Author Manuscript
Future research might also compare African Americans and Caucasians who are dissatisfied with their support systems with those who are satisfied with them. Racial differences may emerge showing dissatisfied African Americans have worse PD than dissatisfied Caucasians, because African Americans may feel let down by the lack of a support system they may normally expect. Such results may suggest it is when group norms for SS are not maintained that racial differences emerge, African Americans experiencing worse mental health and Caucasians experiencing better mental health. Such information may assist mental health professionals in assessing African Americans’ dissatisfaction with their support system and targeting it as a goal for intervention.
References
Author Manuscript Author Manuscript
Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clinical Psychology Review. 2011; 31:934–948. [PubMed: 21683671] Antonucci TC, Akiyama H. An examination of sex differences in social support among older men and women. Sex Roles. 1987; 17(11/12):737–749. Berghout CC, Zevalkink J. Identifying clinical cases among patients assigned to psychoanalytic treatment. Bulletin of the Menninger Clinic. 2008; 72(3):163–178. [PubMed: 18990053] Black AR, Cook JL, Murry VM, Cutrona CE. Ties that bind: Implications of social support for rural, partnered African American women’s health functioning. Women’s Health Issues. 2005; 15:216– 223. [PubMed: 16165007] Bloor LE, Sandler RS, Martin C, Uchino BN, Kinney AY. Associations between emotional support and health-related quality of life among a population-based sample of Blacks and Whites. Journal of Social and Clinical Psychology. 2006; 25(1):96–116. Bosworth HB, McQuoid DR, George LK, Steffens DC. Time-to-remission from geriatric depression: Psychosocial and clinical factors. American Journal of Geriatric Psychiatry. 2002; 10(5):551–559. [PubMed: 12213689] Conway F, Magai C, McPherson-Salandy R, Milano K. Synergy between molecular and contextual views of coping among four ethnic groups of older adults. The International Journal of Aging & Human Development. 2010; 70(4):319–343. [PubMed: 20649162] Derogatis, LR. SCL-90R administration, scoring and procedures manual – II for the R(evised) version. Towson, MD: Clinical Psychometric Research; 1983. Dressler WW. Extended family relationships, social support, and mental health in a Southern Black Community. Journal of Health and Social Behavior. 1985; 26(1):39–48. [PubMed: 3998433] Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007; 39:175– 191. [PubMed: 17695343] Francis LE, Bowman KF, Kypriotakis G, Rose JH. Relationships and emotional wellbeing among African American and White advanced cancer caregivers. Patient Education and Counseling. 2011; 85(3):446–453. [PubMed: 21439755] Frazier PA, Tix AP, Barron KE. Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology. 2004; 51(1):115–134. Gallant MP, Spitze G, Grove JG. Chronic illness self-care and the family lives of older adults: A synthetic review across four ethnic groups. Journal of Cross Cultural Gerontology. 2010; 25:21– 43. [PubMed: 20177963]
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 10
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Gerstel N. Rethinking families and community: The color, class, and centrality of extended kin ties. Sociological Forum. 2011; 26(1):1–20. Goulia P, Papadimitriou I, Machado MO, Mantas C, Pappa C, Tsianos E, Hyphantis T. Does psychological distress vary between younger and older adults in health and disease? Journal of Psychosomatic Research. 2012; 72(2):120–128. [PubMed: 22281453] Hafkenscheid A. Psychometric evaluation of the symptom checklist (SCL-90) in psychiatric inpatients. Personality and Individual Differences. 1993; 14(6):751–756. Hays JC, Landerman LR, George LK, Flint EP, Koenig HG, Land KC, Blazer DG. Social correlates of the dimensions of depression in the elderly. Journal of Gerontology: Psychological Sciences. 1998; 53B(1):31–39. Hayward DR, Krause N. Changes in church-based social support relationships during older adulthood. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences. 2013; 68B: 85–96. Holt CL, Schulz E, Wynn TA. Perceptions of the religion--health connection among African Americans in the Southeastern United States: Sex, age, and urban/rural differences. Health Education and Behavior. 2009; 36:62–80. [PubMed: 17652617] Hu J. Health-related quality of life in low-income older African Americans. Journal of Community Health Nursing. 2007; 24(4):253–265. [PubMed: 18092917] Hu J, Gruber KJ. Positive and negative affect and health functioning indicators among older adults with chronic illnesses. Issues in Mental Health Nursing. 2008; 29:895–911. [PubMed: 18649214] Jesse DE, Swanson MS. Risks and resources associated with antepartum risk for depression among rural southern women. Nursing Research. 2007; 56(6):378–386. [PubMed: 18004184] Krause N, Markides K. Measuring social support among older adults. International Journal of Aging and Human Development. 1990; 30(1):37–53. [PubMed: 2407665] Kubzansky LD, Berkman LF, Seeman TE. Social conditions and distress in elderly persons: Findings from the MacArthur studies of successful aging. Journal of Gerontology: Psychological Sciences. 2000; 55B(4):238–246. Levin J, Chatters LM, Taylor RJ. Religion, health and medicine in African-Americans: Implications for physicians. Journal of the National Medical Association. 2005; 97:237–249. [PubMed: 15712787] Lincoln KD, Taylor RJ, Chae DH, Chatters LM. Demographic correlates of psychological well-being and distress among older African Americans and Caribbean Black adults. Best Practices in Mental Health: An International Journal. 2010; 6(1):103–126. Lindsey MA, Joe S, Nebbitt V. Family matters: The role of mental health stigma and social support on depressive symptoms and subsequent help seeking among African American boys. Journal of Black Psychology. 2010; 36(4):458–482. [PubMed: 20953336] Lubben JE. Assessing social networks among elderly populations. Family & Community Health: The Journal of Health Promotion & Maintenance. 1988; 11(3):42–52. Pallant, J. SPSS survival manual: A step by step guide to data analysis using SPSS for Windows. 3rd. London: McGraw Hill Open University Press; 2007. Peek MK, O'Neill GS. Networks in later life: An examination of race differences in social support networks. The International Journal of Aging & Human Development. 2001; 52(3):207–229. [PubMed: 11407487] Scogin F, Morthland M, Kaufman A, Burgio L, Chaplin W, Kong G. Improving quality of life in diverse rural older adults: A randomized trial of a psychological treatment. Psychology and Aging. 2007; 22(4):657–665. [PubMed: 18179286] Sorkin DH, Pham E, Ngo-Metzger Q. Racial and ethnic differences in the mental health needs and access to care of older adults in California. Journal of the American Geriatrics Society. 2009; 57(12):2311–2317. [PubMed: 19943830] Sriwattanakomen R, McPherron J, Chatman J, Morse JQ, Martire LM, Karp JF, Reynolds CF III. A comparison of the frequencies of risk factors for depression in older black and white participants in a study of indicated prevention. International Psychogeriatrics. 2010; 22(8):1240–1247. [PubMed: 20843391]
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 11
Author Manuscript
Substance Abuse and Mental Health Services Administration. National Survey of Drug Use and Health Report: Serious psychological distress among adults aged 50 or older: 2005 and 2006. Office of Applied Studies, Substance Abuse and Mental Health Services Administration; 2008b Jun 26. Sun F, Hilgeman MM, Durkin DW, Allen RS, Burgio LD. Perceived income inadequacy as a predictor of psychological distress in Alzheimer's caregivers. Psychology and Aging. 2009; 24(1):177–183. [PubMed: 19290749] Trask-Tate A, Cunningham M, Lang-DeGrange L. The importance of family: The impact of social support on symptoms of psychological distress in African American girls. Research in Human Development. 2010; 7(3):164–182. Warren-Findlow J, Laditka JN, Laditka SB, Thompson ME. Associations between social relationships and emotional well-being in middle-aged and older African Americans. Research on Aging. 2011; 33(6):713–734.
Author Manuscript Author Manuscript Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 12
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
FIGURE 1.
Interaction of satisfaction with social support and race on psychological distress.
Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Hyams et al.
Page 13
Table 1
Author Manuscript
Descriptive Characteristics of the Sample African American (n = 64) Characteristic
M (SD) or %
Age
76.23 (7.61)
Caucasian (n = 36)
95% CI
M (SD) or %
95% CI
[74.33, 78.14]
76.17 (6.54)
[73.95, 78.38]
Sex Male
21.9%
Female
78.1%
Incomea
0.95 (2.42)
22.2% 77.8% [0.33, 1.57]
1.11 (1.95)
[0.45, 1.77]
Health
Author Manuscript
Poor
25.4%
55.6%
Fair
46.0%
36.1%
Good
15.9%
8.3%
Very Good
9.5%
0%
Excellent
3.2%
0%
Education (in years)
7.81 (4.01)
[6.81, 8.81]
10.58 (3.26)
[9.48, 11.68]
Total satisfaction with social support
8.40 (2.68)
[7.71, 9.09]
7.51(2.84)
[6.54, 8.49]
Total emotional support
13.35 (4.72)
[12.16, 14.55]
12.51 (5.41)
[10.65, 14.37]
Quality of social support
24.63 (7.73)
[22.61, 26.64]
22.68 (8.35)
[19.76, 25.59]
Total GSI scores
58.22 (8.02)
[56.22, 60.22]
60.81 (10.28)
[57.33, 64.28]
Note. CI = confidence interval. GSI = Global Severity Index. a
The mean income for African Americans and Caucasians lies somewhere between $5,000 and $9,999.
Author Manuscript Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2016 July 21.
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. −1.68 −0.66 −0.80
Self-rated Health
Race
Satisfaction
0.33 −1.75 −0.73 −0.77 −2.08
Self-rated Health
Race
Satisfaction
Interaction (Race × Satisfaction)
0.22
Income
Education
−4.50
Sex
p < .05
*
0.35
Education
.05*
0.19
Income
Step 3
−4.00
Sex
Step 2
.06*
0.35
Education −1.94
0.20
Income
Self-rated Health
−3.91
.10
Step 1
B
Sex
ΔR2
Predictor
[−3.82, −0.35]
[−1.39, −0.15]
[−4.66, 3.20]
[−3.70, 0.20]
[−0.13, 0.78]
[−0.54, 0.99]
[−8.67, −0.34]
[−1.44, −0.16]
[−4.69, 3.38]
[−3.68, 0.33]
[−0.11, 0.82]
[−0.59, 0.98]
[−8.26, 0.26]
[−3.86, −0.03]
[−0.10, 0.80]
[−0.60, 1.00]
[−8.26, 0.44]
95% CI
0.87
0.31
1.98
0.98
0.23
0.38
2.09
0.32
2.03
1.01
0.23
0.39
2.14
0.96
0.23
0.40
2.19
SE
−.23*
−.24*
−.04
−.19
.15
.06
−.21*
−.25*
−.04
−.18
.16
.05
−.19
−.21*
.16
.05
−.18
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Total Satisfaction with Social Support
Author Manuscript
Table 2 Hyams et al. Page 14
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. 0.33 −1.94 −0.41 −0.28 −1.54
Self-rated Health
Race
Quality social support
Interaction (Race × Quality support)
0.33
Income
Education
−4.13
Sex
p < .01
**
p < .05,
*
−0.30
Quality social support .03
−0.61
Race
Step 3
0.35 −1.87
Self-rated Health
0.22
Income
Education
−3.56
Sex
Step 2
.07*
0.34
Education −2.05
0.32
Income
Self-rated Health
−3.78
.11*
Step 1
B
Sex
ΔR2
Predictor
[−3.27, 0.19]
[−0.50, −0.06]
[−4.44, 3.62]
[−3.93, 0.05]
[−0.13, 0.80]
[−0.53, 1.18]
[−8.41, 0.14]
[−0.52, −0.08]
[−4.68, 3.47]
[−3.89, 0.14]
[−0.12, 0.82]
[−0.63, 1.07]
[−7.84, 0.71]
[−4.00, −0.11]
[−0.12, 0.80]
[−0.56, 1.19]
[−8.18, 0.62]
95% CI
0.87
0.11
2.03
1.00
0.23
0.43
2.15
0.11
2.05
1.01
0.24
0.43
2.15
0.98
0.23
0.44
2.21
SE
−.18
−.26*
−.02
−.21
.15
.08
−.19
−.27**
−.03
−.20
.16
.05
−.17
−.22*
.15
.08
−.18
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Quality Social Support
Author Manuscript
Table 3 Hyams et al. Page 15
Author Manuscript
Author Manuscript
Author Manuscript
Clin Gerontol. Author manuscript; available in PMC 2016 July 21. −4.38 0.43 0.32 −2.20 −0.12 −0.44 −1.53
Sex
Income
Education
Self-rated Health
Race
Emotional support
Interaction (Race × Emotional support)
p < .01
**
p < .05,
*
−0.48
Emotional support .03
−0.11
Race
Step 3
0.33 −2.14
Self-rated Health
0.30
Income
Education
−3.90
Sex
Step 2
.07*
0.34
Education −2.42
0.39
Income
Self-rated Health
−4.17
.14*
Step 1
B
Sex
ΔR2
Predictor
[−3.16, 0.11]
[−0.79, −0.10]
[−4.10, 3.87]
[−4.12, −0.28]
[−0.14, 0.78]
[−0.42, 1.27]
[−8.53, −0.22]
[−0.83, −0.13]
[−4.15, 3.94]
[−4.09, −0.20]
[−0.13, 0.80]
[−0.55, 1.14]
[−8.07, 0.28]
[−4.29, −0.56]
[−0.12, 0.79]
[−0.47, 1.26]
[−8.47, 0.12]
95% CI
0.82
0.17
2.01
0.97
0.23
0.42
2.09
0.18
2.03
0.98
0.24
0.42
2.10
0.94
0.23
0.44
2.16
SE
−.18
−.24*
−.01
−.23*
.14
.10
−.20*
−.27**
−.01
−.23*
.15
.07
−.18
−.26*
.15
.09
−.19
β
Hierarchical Multiple Regression of PD on Covariates, Race, and Emotional Support
Author Manuscript
Table 4 Hyams et al. Page 16
