Title: Florida heart study
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Title: Florida heart study psychosocial adjustment of Hispanic heart patients
Physical Description: Book
Language: English
Creator: Urizar, Guido G., 1974-
Publisher: University of Florida
Place of Publication: Gainesville Fla
Gainesville, Fla
Publication Date: 2001
Copyright Date: 2001
 Subjects
Subject: Hispanic, Latino, heart disease, psychosocial factors, quality of life, depression, acculturation
Clinical and Health Psychology thesis, Ph. D   ( lcsh )
Dissertations, Academic -- Clinical and Health Psychology -- UF   ( lcsh )
Genre: government publication (state, provincial, terriorial, dependent)   ( marcgt )
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non-fiction   ( marcgt )
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Abstract: ABSTRACT: Previous research has indicated that patients with heart disease often face psychological complications and difficulties in adjustment due to the chronic nature of their illness. However, very few researchers have attempted to examine dimensions of patient adjustment in Hispanic cardiac populations or the influence of psychosocial and cultural factors on their health outcomes. Therefore, the purpose of this study was to examine the relationship of Hispanic patient characteristics on dimensions of cardiac-related quality of life (CQOL). The current study assessed 120 Hispanic patients diagnosed with coronary heart disease (CHD) during scheduled visits to their cardiologist. Questionnaires were administered consisting of background information, acculturation, depression, familism, fatalism, social support, and cardiac-related quality of life.
Abstract: Three separate hierarchical stepwise regression analyses were conducted to examine the degree of association between the five independent explanatory variables (social support, depression, acculturation, familism, and fatalism) and each of the three dependent variables (physical functioning, emotional functioning, social functioning). All analyses controlled for patient age, gender, SES, medical severity, and time since diagnosis by entering these variables into the model first (Block I), with the psychosocial variables being entered second (Block II), followed by the cultural variables, in a stepwise manner (Block III). An overwhelming majority of Hispanic patients (91.7%) were classified as "low acculturated," with high levels of social support (85.8%), and moderate to high cardiac-related quality of life (84.2% to 85.8%). However, 14% to 16% of cardiac patients reported adjustment difficulties in the areas of physical (14.2%), emotional (14.2%), and social (15.8%) functioning, respectively. In addition, approximately 26% of Hispanic patients reported experiencing significant depressive symptomatology.
Abstract: In general, depression, high medical severity, and female gender predicted lower patient functioning across the three dimensions of CQOL. Although acculturation, was not a significant predictor of CQOL, the Hispanic cultural values of fatalism and familism had an indirect influence on patient adjustment through depression and social support, respectively. These findings suggest that interventional programming focus on subgroups of Hispanic cardiac patients that may be at increased risk for developing depressive symptomatology and/or experience adjustment difficulties related to their heart disease. Understanding dimensions of Hispanic culture may help health care professionals in promoting quality of life in this patient population.
Thesis: Thesis (Ph. D.)--University of Florida, 2001.
Bibliography: Includes bibliographical references (p. 73-87).
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System Details: Mode of access: World Wide Web.
Statement of Responsibility: by Guido G. Urizar Jr.
General Note: Title from first page of PDF file.
General Note: Document formatted into pages; contains x, 99 p.; also contains graphics.
General Note: Vita.
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Bibliographic ID: UF00100849
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
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Resource Identifier: oclc - 78525630
alephbibnum - 002763027
notis - ANP1047

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FLORIDA HEART STUDY: PSYCHOSOCIAL ADJUSTMENT OF
HISPANIC HEART PATIENTS

















By

GUIDO G. URIZAR JR.


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2001
















ACKNOWLEDGMENTS

This paper is dedicated to my late grandmother, Maria L6pez Zeballos, who was

instrumental in exposing me to my Bolivian heritage early on in childhood, serving as a

tremendous inspiration for this study. Not only was she a strong, positive role model in

my life, but she provided me with immeasurable emotional support during my education

and upbringing. Special thanks also go to my parents, Guido and Gladys Urizar, whose

work ethic, sacrifice, and dedication to patient care influenced my decision to pursue a

career in the health professions. I would like to extend a heartfelt thank you to my

Taekwondo family in Miami, FL (Grandmaster Soo Se Cho, Gordon Thomas, Diane

Landsberg, and Tom McCardle) who helped me to achieve balance in my life, prepared

me to deal with life's challenges, and taught me the value of infinite growth.

I would not have gotten to this point in my graduate education without the

friendship and support of my classmates and peers at the University of Florida (in

particular Brian Sirois, Emily Wise, Tara Saia-Lewis, Robert Newton, LaToya Akers,

Caroline Danda, Caren Jordan, and Robyn Wallace) who each served instrumental roles

in my personal and career development. I will always treasure our times of laughter,

tears, and perseverance. The completion of this study would not be possible without the

instrumental support of the cardiologists (Dr. Fernando Villacian and Dr. Edgardo

Cespedes) and nursing staff at the Cardiovascular Interventions of Miami Clinic, and the









dedicated efforts of the research team (Jennifer Veseda, Betzabeth Andres, Devorah Gil,

Jessica Urizar and Kimberly Brothers).

I wish to extend my sincerest appreciation to the esteemed members of my

doctoral committee, Dr. Cynthia Belar, Dr. Duane Dede, Dr. Garret Evans, and Dr. James

Jessup, for their guidance and support throughout my graduate training. Finally, I would

like to thank my dissertation chairman, Dr. Samuel Sears. He has been a mentor in every

sense of the word, demonstrated by his level of professionalism, dedication, and

enthusiasm to the field of psychology. The level of support and guidance he has provided

me, on both a professional and personal level, are qualities that I will value and hope to

emulate as I progress in my career development.
















TABLE OF CONTENTS

page

A CKN OW LED GM EN TS ..................................................................... ii

LIST OF TABLES................... .................. ................... .. ......... vii

LIST OF FIGURE S .......... .... .......................................... ..... ... viii

A B STR A C T ......... .. ........... ..................... ............... ........ ......ix

REVIEW OF LITERATURE ....................................... .... .. ....... .............

Research with Hispanic Populations............ ................. ................ 1
Acculturation Theory ............................. ..................... .2
Acculturation Measurement.............. ...... ....... .............3
Coronary Heart Disease (CHD) in Hispanics.......................... ................5
Coronary Heart Disease Mortality.........................................5
Cardiovascular Risk Factor Profile.............. ............................6
Psychosocial Factors in Heart Disease....................................................8
Depression........................... ...................... ......... 9
D expression in Hispanic Populations...............................................9
Fatalism ................. ............. .............. ......... 1
Depression and CHD ..................... ....................... ........... . 12
Depression in Hispanic CHD Populations ..................................... 14
Social Support ....................................... ........ .......... .... .......... 16
Social Support in Hispanic Populations .......... ............................16
Social Support and CHD ..................................................... .18
Social Support and Depression............ ....... ........ ............... 19
Familism ................................ .................. .......... 20
Health-Related Quality of Life .......................................................... .22
Psychosocial Adjustment to Heart Disease.....................................23
Acculturation and Health-Related Quality of Life............................25
Methodological Critique...... ............................... .29
Aims of the Current Study ............... ................ ...... .............. 31
Hypotheses........... .....................................................32









M E T H O D .................................................................. ........... 34

Participants ........................ .............. ........................ .... ..34
M measures ............... .. ....................... ................... ... ........ 36
Background Questionnaire .............................. ....................36
Center for Epidemiological Studies-Depression Scale..................... 39
Fam ilism Scale................ .............. ................ ............. 39
Fatalism/Mastery Scale .............. ................... ....................40
MacNew Quality of Life after Myocardial Infarction Questionnaire.......40
MOS Social Support Survey.......... .......................................41
Short Acculturation Scale for Hispanics..................................... 42

RESULTS................................................................ ................ 43

Incidence of Depression, Degree of Acculturation, Social Support & CQOL.....43
Relationships Between QOL Dimensions and Cardiac Pt Study Variables........43
Patient Characteristics Influencing Cardiac-Related Quality of Life...............44
Regression Models for Dimensions of Cardiac-Related Quality of Life............45
Physical Functioning........................ ...... .......................49
Emotional Functioning .......................................................... 49
Social Functioning............... .. .... ... ......... ........ ........ ........52
Regression Models for Depression and Social Support........... ..............52
D epression.............................. .................. ......... 53
Social Support................ ........... ... ....................... ............ 54

DISCUSSION.................................... ...................... ..... .......... 55

Hispanic Patient Sample .................. ............................. ...............55
Multidimensional Assessment of Hispanic Acculturation........... .............. 56
Cardiac-Related Quality of Life .............. ...................................... 57
Physical Functioning..................... ....................... ........... ...57
Social Functioning...................... ..................... .......... ...... 58
Emotional Functioning ..................................................58
Time Since Diagnosis................. ....................................5........59
Psychosocial Risk Factors................................... .......... ...............60
Women and CHD ........................................................ .........61
L im itations...................................... .................... .. ....... 62
Future D directions .................................... ................ ......... 64

R E FE R EN C E S ................................................................ ............ 73

APPENDIX A PATIENT INFORMATION INTERVIEW ..................................88









APPENDIX B CES-D MEASURE............... .................... ......................90

APPENDIX C FAMILISM SCALE........................... .................91

APPENDIX D FATALISM SCALE............ .............................92

APPENDIX E QUALITY OF LIFE MEASURE.........................................93

APPENDIX F SOCIAL SUPPORT MEASURE............ ..........................97

APPENDIX G ACCULTURATION MEASURE .............. ...........98

BIOGRAPHICAL SKETCH ........ .... ........ ....... ................... .......... 99
















LIST OF TABLES


Table page

1 Demographic Characteristics of Study Participants............................37

2 Cardiovascular Risk Factor Profile of Study Participants........................38

3 Correlations, Means, and Standard Deviations of Study Variables .................46

4 Summary of Final Regression Analyses for Variables
Predicting Three Dimensions of Cardiac-Related Quality of Life,
Depression, and Social Support ................... ............. .... ............... 51
















LIST OF FIGURES


Figure p

1 Mean Scores of Global Quality of Life by Time Since Cardiac Diagnosis ........47

2 Mean Scores of Global Quality of Life by NYHA Class ............. ..........48

3 Models for the Three Planned Regression Analyses ......... ...............50
















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

FLORIDA HEART STUDY: PSYCHOSOCIAL ADJUSTMENT OF
HISPANIC HEART PATIENTS

By

Guido G. Urizar Jr.

August 2001


Chairperson: Samuel F. Sears, Jr., Ph.D.
Major Department: Clinical and Health Psychology

Previous research has indicated that patients with heart disease often face

psychological complications and difficulties in adjustment due to the chronic nature of

their illness. However, very few researchers have attempted to examine dimensions of

patient adjustment in Hispanic cardiac populations or the influence of psychosocial and

cultural factors on their health outcomes. Therefore, the purpose of this study was to

examine the relationship of Hispanic patient characteristics on dimensions of cardiac-

related quality of life (CQOL).

The current study assessed 120 Hispanic patients diagnosed with coronary heart

disease (CHD) during scheduled visits to their cardiologist. Questionnaires were

administered consisting of background information, acculturation, depression, familism,

fatalism, social support, and cardiac-related quality of life.









Three separate hierarchical stepwise regression analyses were conducted to

examine the degree of association between the five independent explanatory variables

(social support, depression, acculturation, familism, and fatalism) and each of the three

dependent variables (physical functioning, emotional functioning, social functioning).

All analyses controlled for patient age, gender, SES, medical severity, and time since

diagnosis by entering these variables into the model first (Block I), with the psychosocial

variables being entered second (Block II), followed by the cultural variables, in a

stepwise manner (Block III).

An overwhelming majority of Hispanic patients (91.7%) were classified as "low

acculturated," with high levels of social support (85.8%), and moderate to high cardiac-

related quality of life (84.2% to 85.8%). However, 14% to 16% of cardiac patients

reported adjustment difficulties in the areas of physical (14.2%), emotional (14.2%), and

social (15.8%) functioning, respectively. In addition, approximately 26% of Hispanic

patients reported experiencing significant depressive symptomatology. In general,

depression, high medical severity, and female gender predicted lower patient functioning

across the three dimensions of CQOL. Although acculturation, was not a significant

predictor of CQOL, the Hispanic cultural values of fatalism and familism had an indirect

influence on patient adjustment through depression and social support, respectively.

These findings suggest that interventional programming focus on subgroups of

Hispanic cardiac patients that may be at increased risk for developing depressive

symptomatology and/or experience adjustment difficulties related to their heart disease.

Understanding dimensions of Hispanic culture may help health care professionals in

promoting quality of life in this patient population.
















REVIEW OF LITERATURE

Research with Hispanic Populations

Hispanics are the fastest growing minority in the United States. Since 1980, the

Hispanic population has increased 34%, while the non-Hispanic population has increased

only 7%. By the year 2000, Hispanics will number an estimated 31 million, the largest

minority group in the United States (Mein & Winkleby, 1998). Within the Hispanic

community lies a diverse population, with the term Hispanic encompassing many

different national origins and cultures.1 Of the 19.4 million Hispanics residing in the

United States, 62.3% are of Mexican origin, 12.7% are Puerto Rican, 5.3% are Cuban,

11.5% are Central or South American, and 8.1% are of other Hispanic origin (U.S.

Bureau of the Census, 1993).

Hispanic groups in the U.S. encounter many financial, educational, and cultural

factors that impact their health and health care behaviors. For example, compared with

non-Hispanics, Hispanics are less likely to have health insurance coverage. As a result,

the uninsured are less likely to have a regular source of health care, less likely to have

seen a physician within the previous year, and less likely of ever having received a

complete physical examination. Consequently, this group tends to rate their own health

status highly (Trevino, Moyer, Valdez, & Stroup-Benham, 1991). Aspects of Hispanic



For the purposes of this manuscript the label "Hispanic" will refer to those residents of the United States
who trace their family background to one of the Spanish-speaking Latin American nations or to Spain
(Federal Register, 1978). However, it is recognized that this label is not universally accepted by its
referents, and that alternative labels have been suggested (e.g., Latino, Latin American).






2


culture have also been found to influence one's health through interpretation of

symptoms, help-seeking behavior, patient compliance with health care recommendations,

and adjustment to illness (Angel & Angel, 1997). One cultural construct that has been

examined in Hispanic health care research is acculturation.

Acculturation Theory

Acculturation refers to a process of cultural learning and behavioral adaptation

that takes place as individuals are exposed to a new culture (Berry, 1998; Padilla, 1995).

Berry (1998) has proposed that upon contact with a new culture, individuals undergo a

process of change in any or all of six areas of functioning: language use, cognitive style,

personality, identity, attitudes, and stress. This process of change, or acculturation, is

described by Berry as an initial stage of crisis or conflicts that is then followed by the

acceptance of an adaptation strategy. In terms of language, for example, Hispanics may

completely shift to English, become bilingual, or maintain Spanish as their primary

language. Cultural change from both time (exposure to the dominant culture) and

migration impacts Hispanics living in the U.S. today, revealing the damaging, as well as

the protective, health aspects of this particular ethnic group. However, it is not

necessarily the cultural change that affects health, but the extent to which cultural values,

rules of behavior, and traditional ways of coping are affected (Corin, 1994).

The construct of acculturation is a frequently used, convenient, and well-

established criterion for understanding and assessing intra-group cultural variance within

the Hispanic population (Cuellar, Arnold, & Maldonado, 1995). The importance of

acculturation as a variable that differentiates among Hispanic subgroups can be seen in

the large number of studies establishing this construct as a significant modifying health









variable. Acculturation has been found to play an important role in determining the

health behavior of elderly Hispanics (Marks et al., 1990), levels of social support

(Griffith & Villavicencio, 1985), Hispanics' mental health status (Burnam et al., 1987),

and in the incidence of disease (Moscicki et al., 1989).

Although there have been various models of acculturation presented in recent

literature (LaFromboise, Coleman, & Gerton, 1993), Keefe and Padilla (1987) present a

multidimensional model that endorses the concept of selective acculturation, whereby an

individual can adopt specific values, traits, and customs, while simultaneously retaining

other traditional values, traits, and customs. This model represents a process similar to

biculturalism an individual's ability to become fluent in both cultures. Therefore, this

model attempts to recognize the various complexities inherent to the acculturation

process and will serve as the theoretical framework for the current study.

Acculturation Measurement

Due to the complex nature of the acculturation process, measures of acculturation

have been conceptualized in a number of different ways, taking into consideration the

cultural heterogeneity of the Hispanic population. Measures of acculturation typically

assess where individuals are in a process of psychosocial change that involves the

adaptation to a new culture. This process includes changes in behavior, values, ethnic

loyalty, social relationships, language use, and food preferences (Cuellar et al., 1980;

Olmedo, 1979; Szapocznik et al., 1978). Some individuals follow patterns of language,

behavior, and values close to those of their native culture, while others live a lifestyle

very close to that of the host culture; a large portion of Hispanic Americans fall

somewhere between these two extremes.









Language use has become one of the most objective and simple methods of

quantifying and evaluating the process of acculturation in Hispanic populations, being

significantly correlated with various behavioral and health indices (Negy & Woods,

1992; Sabogal et al., 1989). Nevertheless, prior studies have demonstrated that when

language was used alone as a measure of acculturation, about 12% of the respondents

were misclassified when compared with their scores on a multidimensional, valid and

reliable acculturation measure (Marin & Marin, 1991). A developing literature suggests

that an individual's cultural values and norms (those cognitive constructs that describe

people's worldviews and interaction patterns) are a more permanent and accurate

reflection of actual cultural learning (Cuellar et al., 1995; Marin, 1993). Examples of

group-specific values and norms of Hispanics that could change as a function of

acculturation are familism (Sabogal et al., 1987) and fatalism (Neff& Hoppe, 1993). In

fact, Sabogal and colleagues (1987) demonstrated that some aspects of familism (i.e.,

familial obligation and perception of family as referents) change as a function of

acculturation, whereas others remain stable (i.e., family support). Thus, acculturation can

be measured both behaviorally and cognitively and both methods of measurement have

potential contributions in understanding the influence of culture on health.

In summary, it is apparent that the definition and operationalization of

acculturation has changed in research throughout the years. Currently, it has moved

away from a simplistic unidimensional process (e.g., language measurement) and now

emphasizes a comprehensive, multidimensional approach. Central to this new

understanding of acculturation is the fact that the acculturating individual is now

perceived as a person who may indeed be comfortable in both cultures and who, by









acculturating, is gaining new cultural knowledge and information rather than sacrificing

previously held abilities or values. It is essential then, that future research consider

acculturation as a fluid process (lifelong event) that involves many dimensions of an

individual's life (e.g., behaviors, attitudes, norms, and values) and implies growth along a

continuum, a methodological approach that will be emphasized in the current study.

Coronary Heart Disease in Hispanics

Although most research on the health problems of American ethnic groups has

been recent, studies performed during the past two decades have uncovered findings of

clinical and public health importance. In particular, epidemiologic investigations of

Hispanics in the United States have identified a variety of diseases that differ in

frequency from those of Anglo Americans. The current literature review will consider

one of these in detail coronary heart disease (CHD). Mortality data will be presented as

well as the cardiovascular risk factor profile for Hispanics across levels of acculturation.

Coronary Heart Disease Mortality

Despite encouraging declines in heart disease mortality rates, more people in the

United States die from coronary heart disease (CHD) each year than from any other

cause, accounting for 20.4% of all adult deaths (American Heart Association, 1999). The

cost to the U.S. economy is over $117 billion per year (Shapiro, 1996). Coronary heart

disease is caused by atherosclerotic narrowing of the coronary arteries and can result in

congestive heart failure (CHF), myocardial infarction (MI), angina pectoris, cardiac

dysrhythmia, conduction defects, and sudden death. Similar to its effects on the general

U.S. population, CHD is also the leading cause of death among Hispanics residing in the

United States, regardless of gender or country of origin (Moreno et al., 1997). In 1993,









23.9% of all deaths among Hispanics resulted from CHD (National Center for Health

Statistics, 1996).

Despite extensive studies during the last decade, data regarding the incidence,

prevalence, and mortality of CHD in Hispanics are limited. Until recently, most

information related to CHD mortality in Hispanic populations had been limited to

regional and national vital statistics data, suggesting that cardiovascular mortality in the

Hispanic population was approximately 20% lower than in the rest of the Anglo-

American population (Becker et al., 1988; NCHS, 1996). However, this lower trend in

CHD mortality has relied on archival data and has been less clearly established in

Hispanic American women (Goff et al., 1993; Wild et al., 1995). Despite the

methodological limitations of prior research, results from two recent national cohort

studies (National Longitudinal Mortality Study, Sorlie et al., 1993; National Health

Interview Survey, Liao et al., 1997) helped verify earlier findings, demonstrating that

Hispanic Americans had significantly lower CHD mortality than Anglo Americans. In

addition, adjustment for differences in income demonstrated even larger disparities in

Hispanic to Anglo-American mortality rates. The consistency of these findings is

surprising given that the Hispanic population has a higher prevalence of several known

risk factors for CHD, which will be discussed in more detail below.

Cardiovascular Risk Factor Profile

A less favorable cardiovascular risk factor profile has been documented in

Hispanics when compared to Anglo Americans. On average, Hispanics have higher body

mass indexes (Mitchell et al., 1990), more central obesity (Burchfiel et al., 1990), a

higher prevalence of diabetes mellitus (Hazuda et al., 1988; Stern et al., 1981, 1984),









lower HDL cholesterol and higher triglyceride levels (Mitchell et al., 1990), and lower

engagement in exercise behaviors (Burchfiel et al., 1990; Shea et al., 1991). However,

cigarette smoking appears to be less prevalent (Haynes et al., 1990; Marcus & Crane,

1985), and the prevalence of hypertension is comparable to that of Anglo Americans

(Burchfiel et al., 1990; Caralis, 1990).

Although many studies have assessed the association of genetic influence, SES,

education, employment, and acculturation with selected cardiovascular risk factors, they

have reached mixed results. It has been noted that with rising SES, higher education, and

acculturation, there exist increased knowledge and less behavioral avoidance in the

management of hypertension and cholesterol among Hispanics (Atkins et al., 1987). In

contrast, the prevalence of cigarette smoking has increased in Hispanics of both sexes as

acculturation to the mainstream culture has occurred (Perez-Stable, 1987; Sabogal et al.,

1989). Finally, Hispanics with higher levels of acculturation have demonstrated

increased levels of exercise (Vega et al., 1987) and decreased prevalence of both diabetes

(Hazuda et al., 1988; Stern et al., 1984) and obesity (Vega et al., 1987).

It is apparent from available data that the prevalence of specified risk factors for

CHD varies between Hispanics and Anglo Americans. However, it is not currently

known whether such differences are primarily due to sociocultural, behavioral, or genetic

factors. In addition, available data on the prevalence of these risk factors in Hispanics do

not adequately explain the lower rate of CHD mortality in this population. Therefore, it

is evident that more research on health knowledge, health behaviors, and patterns of

health care utilization in this population is warranted. Finally, because most of the

studies cited in this review have subject samples of Hispanics from circumscribed regions









of the U.S. (i.e., Puerto Rico, northern or southern California, and southern Texas), these

Hispanic subjects are not necessarily representative of the Hispanics in other regions of

the U.S. Therefore, the results presented are limited and should be looked upon as best

estimates of population trends based upon the available data.

In summary, although the impact of coronary heart disease (CHD) is widely

acknowledged in the Hispanic population, data on the incidence, prevalence, risk factors,

and morbidity of CHD among this group are limited in the literature. Studies on coronary

heart disease risk factors imply that compared to the Anglo-American population,

Hispanics (1) have more of the risk factors attributable to the incidence and prevalence of

CHD, (2) have less knowledge about CHD risk factors, and (3) engage less in heart

healthy diet and exercise (Juarbe, 1996). In addition, the process of acculturation has

generally been associated with decreased prevalence of CHD risk factors. Overall, the

data that exist for Hispanics in the U.S. indicate that Hispanics have a lower mortality

rate from CHD than do Anglo Americans (Liao et al., 1997; Sorlie et al., 1993).

Nevertheless, the limited mortality information available clearly demonstrates that CHD

is by far the leading cause of death among Hispanics in the United States (Derenowski,

1990; National Center for Health Statistics, 1996).

Psychosocial Factors in Heart Disease

Recent evidence has suggested that behavioral and psychosocial factors play a

significant and independent role in the development of coronary heart disease (CHD) and

its complications (Blumenthal et al., 1997). In addition, it has become increasingly

apparent that traditional risk factors (e.g., cigarette smoking, hypertension) do not fully

account for the development of CHD or for the triggering of adverse cardiac events, as









they account for approximately 40% of CHD occurrence (Marmot & Winkelstein, 1975;

Muller et al., 1994). Further, a growing body of evidence suggests that psychosocial

factors are important predictors of prognosis in patients following a cardiac event and,

conversely, can develop as complications of CHD. The following sections present two of

these psychosocial factors depression and social support in relation to their influence

on the development and progression of heart disease in Hispanic populations.

Depression

Depression in Hispanic Populations

The most significant health problem in Hispanics immigrating to the United

States may lie in the area of mental health. Hispanics entering the U.S. confront a major

adaptation process that manifests in many different ways. Although many adapt well,

some Hispanic Americans experience adjustment difficulties leading to depression.

Depressive symptoms have been found to be significantly greater among Mexican

Americans (28.9%) when compared with a cohort of Anglo-American (14.6%) and

African-American (18.1%) subjects (Roberts, 1981). Rates of depression may increase

among people of low socioeconomic status, decreased level of education, and low

availability of social support (Frerichs et al., 1981). In general, acculturative stress,

female gender, low socioeconomic level, and alcohol consumption are risk factors

associated with increased Hispanic susceptibility to stress disorders and depression

(Rodriguez, 1996).

The Hispanic Health and Nutrition Examination Survey (HHANES) has provided

the most extensive prevalence data on depression in the U.S. Hispanic population to date

(Moscicki et al., 1987). According to the HHANES study, the overall prevalence rates of









depressive symptomatology, based on the CES-D, for Mexican Americans (n = 3,555),

Cuban Americans (n = 902) and Puerto Ricans (n = 1,343) were 13.2%, 10.2%, and

27.7%, respectively. Additionally, the six-month prevalence rates for major depressive

episode in these populations were 2.3%, 2.2%, and 5.8%, respectively. In general, these

findings are lower than earlier studies examining Mexican Americans (Roberts, 1981).

Further, these findings are lower for Cuban Americans and higher for Puerto Ricans

when compared to CES-D estimates for non-Hispanic populations.

Low levels of acculturation have been associated with increased psychological

distress due to the initial lack of knowledge and resources available as one attempts to

cope with the stress of adapting to a new culture. For example, Vega and colleagues

(1984) found similar levels of depressive symptoms in Anglo Americans and English-

speaking Mexican Americans, but significantly higher levels of depressive symptoms in

Spanish-speaking Mexican Americans. Since language preference is generally thought to

be a broad indicator of acculturation, these data suggest that the relative lack of societal

integration resulting from low acculturation may account for increased psychological

distress among Hispanics. Therefore, it would be expected that Hispanic heart disease

patients with low social resources and consequent depressive symptoms would have more

difficulty adjusting to their cardiac illness compared to their highly acculturated

counterparts. As will be discussed in the following section, the manner by which

individuals appraise life events and choose to cope with the process of cultural adaptation

may exacerbate levels of distress.









Fatalism

Fatalism is defined as the extent to which people feel their destinies are beyond

their control, reflecting the individual's perception of low mastery and therefore

influencing health outcomes through passive coping responses (Cuellar et al., 1995).

Both Mexican Americans (Chandler, 1979) and African Americans (McCarthy &

Yancey, 1971) have been found to be more fatalistic than Anglo Americans.

Furthermore, although fatalistic attitudes are said to result in greater distress (Mirowsky

& Ross, 1984), fatalism has also been interpreted as a potentially adaptive response to an

uncontrollable life situation often experienced by minorities (Neff & Hoppe, 1993).

Additionally, although fatalism may imply a lack of perceived individual control,

a characteristic typically associated with depression, the adverse effects of fatalism have

been demonstrated to be offset by social resources, such as religious involvement and

integration into the mainstream culture (Krause & Tran, 1989). For example, fatalistic

attitudes have been associated with lower levels of depression for those Mexican

Americans in the low and high ends of the acculturation continuum compared to those

individuals not fully integrated in one culture or the other (Neff & Hoppe, 1993). These

findings imply that both minimally and highly acculturated individuals may be protected

from the adverse effects of fatalism the former through integration in traditional value

systems (e.g., religion, familism), and the latter through integration into the Anglo-

American culture (e.g., greater language fluency). However, it is the partially

acculturated or "marginalized" individual (alienated from traditional culture but not yet

integrated into the dominant culture) that appears to have fewer coping resources and,

consequently, higher levels of distress.









These findings point to the need for further research clarifying cross-cultural

differences in fatalism in order to understand its potential as an adaptive or maladaptive

coping strategy in relation to chronic medical conditions. Whether fatalistic attitudes

result in greater distress, or whether fatalistic attitudes result from uncontrollable life

situations that are distressful, such as chronic illness, is not presently clear. In either

scenario, fatalism is believed to be associated with adjustment difficulties, particularly in

chronically ill populations, and mental health problems such as depression.

Depression and CHD

Depression is one of the most common comorbid illnesses observed in chronic

diseases. In the general population, the lifetime risk of depression is 10 to 25 percent for

women and 5 to 12 percent for men (American Psychiatric Association, 1994). However,

the prevalence of depression in those with chronic illnesses is much higher 25 to 33%

(Katon & Sullivan, 1990). Depression is a common but frequently underdiagnosed and

undertreated psychiatric illness in patients who have CHD, with less than 25% of patients

with depressive symptomatology diagnosed as depressed by their cardiologist and only

about half of those patients receiving treatment (Carney et al., 1995). The presence of

comorbid medical conditions may complicate the assessment of depression by masking

or mimicking symptoms of depression. This phenomenon is particularly apparent in

Hispanic patients where depressive symptoms may be manifested in somatic terms

(Angel & Guarnaccia, 1989; Katon, Kleinman, & Rosen, 1994). Approximately 20% to

40% of patients with CHD exhibit depressive symptoms, with 18% meeting criteria for

current major depression (Carney et al., 1995). In addition, there is evidence that 50% of

post-MI patients with major depression either remain depressed or relapse within 12









months and that 42% of patients with minor depression subsequently develop major

depression (Hance et al., 1996). These data demonstrate that significant depressive

symptoms and episodes of major depressive disorder are common findings in patients

during the post-MI period and, if left untreated, minor depression is likely to progress to

major depression, rather than to remit, over the course of 12 months post-MI.

Recent research has clearly documented that increased levels of depressive

symptomatology adversely affect the prognosis of cardiac illness in patients following a

cardiac event through interference during the recovery period, increased mortality, and

diminished patient quality of life. Depression in CHD patients has been associated with

high medical care utilization, amplification of somatic symptoms and disability, poor

self-care and adherence to medical regimens, and increased morbidity and mortality from

their medical illness (Katon & Sullivan, 1990). Specifically, studies have demonstrated

that patients who meet criteria for major depressive disorder following myocardial

infarction (MI) are at increased risk of recurrent cardiac events (Barefoot & Schroll,

1996; Frasure-Smith et al., 1995) and are 5 to 6 times more likely to die during the

ensuing 6 months even after controlling for other prognostic risk factors (Frasure-Smith

et al., 1993). Further, the combination of CHD and depressive symptomatology has been

associated with roughly twice the reduction in social functioning associated with either

depression or CHD alone (Wells et al., 1989). In addition, the prevalence of depression

has been reported to be at least twice as high among women as men with CHD, which

may help to explain why the mortality rate following MI is higher in women than in men

(Carney et al., 1995; Kessler et al., 1994). Together the available observations indicate

that depression is a risk factor for poor prognosis in patients with heart disease, affecting









several areas of patient adjustment. Therefore, appropriate treatment for depression in

heart disease patients is important in light of its high prevalence and negative effects.

Depression in Hispanic CHD Populations

Surprisingly, few studies adequately describe their samples with regard to basic

demographics (gender, ethnic identity, SES, marital status) and medical status when

presenting research findings related to comorbid depression in CHD populations (Hill et

al., 1992). In addition, the vast majority of studies reviewed above have been conducted

primarily in Anglo-American adult male samples, which points to the tremendous need

for research with women, minorities, and children in this area of study. Given that

depression is a common finding in patients following a cardiac event, Hispanic CHD

patients may experience added difficulties with medical adjustment due to specific

acculturative stressors (e.g., language barriers, lack of economic resources, limited

knowledge of available services), which may thereby increase their risk of exhibiting

depressive symptoms. Additionally, low emotional support from extended family

relationships among Hispanics might enhance the mental health impact of CHD in this

patient population.

Although there have been few studies examining the relationship between

depression and CHD in Hispanic populations, Nanjundappa and Friis (1985) examined

the interrelationship of diabetes and depressive symptoms in a sample of 56 Mexican and

Anglo-American patients. Results indicated that nearly 70% of Mexican-American

diabetes cases (17 of 22) presented with depressive symptomatology as measured by the

CES-D (score of 16 or higher). In addition, Mexican-American ethnicity, non-

employment status, and lack of social support were found to predict depression in this









patient population. A more recent study investigated the relationship between the

presence of angina and depressive symptoms in 1,558 Mexican-American women (n = 98

with angina) participating in the HHANES study (Portillo et al., 1995). Mexican-

American women with angina were found to have significantly higher symptoms of

depression compared to those without angina (11.5 vs. 9.0, p < .05). Furthermore,

functional impairment, not being married, and poverty were significantly associated with

higher ratings of depression, with functional impairment having a stronger association

with depressive symptoms than angina or physical inactivity.

These findings point to the importance of social isolation and economic necessity

as risk factors for the development of depressive symptoms in Hispanic cardiac

populations. Furthermore, the results of these studies establish the saliency of the

acculturation process in patient adjustment to chronic illness. Mexican Americans are

likely to experience greater social and economic stressors in relation to cultural

adaptation as immigrants to the U.S. experience detachment from previously established

social networks and family relationships. Consequently, effective health seeking

behaviors may be further complicated by restricted knowledge of public resources, low

socioeconomic status, language barriers, and external attributions to mental health

problems.

Although these results provide some information on previously nonexistent data

regarding rates of depression in Hispanic patients with heart disease, the results should be

interpreted with caution. For instance, the focus of these two studies on Mexican

Americans limits the utility and generalizability of the results to other Hispanic samples

diagnosed with heart disease. In addition, patients with other manifestations of heart









disease, such as heart failure, or in a more severe stage of their heart disease may present

with a varied clinical presentation of depression. Nevertheless, these findings

demonstrate that depression is highly prevalent in Hispanics with chronic medical

conditions, reflecting the need for psychosocial interventions and further research in this

patient population.

In summary, the findings presented indicate (1) the prevalence of depression in

the U.S. Hispanic population is similar or higher to that of the general population, (2) the

prevalence of depression varies across Hispanic subgroups, level of acculturation, SES

status, and gender, (3) the cultural construct of fatalism has been associated with

depression in Hispanic populations, varying as a function of acculturation and having

potential to increase our understanding of adjustment difficulties in chronically ill

populations, (4) depression is a common comorbid illness in patients with CHD and it is a

risk factor for poor prognosis in these patients on multiple levels, and (5) data on

comorbid depression in Hispanic patients with CHD are virtually nonexistent and point to

the need for studies examining this area of research.

Social Support

Social Support in the Hispanic Population

Social support among Hispanics has been traditionally studied from an extended

family perspective. Social support systems, levels of stress, and psychological

dysfunction (in particular, depression) among Hispanics have suggested that the buffering

role of social support in the stress-illness paradigm can be generalized to this population

(Salgado de Snyder & Padilla, 1987). More recent research in the social support

literature has emphasized that quality more than strictly quantity is the support variable









that protects people in crisis (Sherbourne & Stewart, 1991). Furthermore, among

Hispanic immigrants, adequate social support seems to facilitate cultural adaptation and

the development of successful coping strategies.

Whether an extended family system functions as a source of support or as a

source of stress depends also upon the needs of the individual. In the case of second- and

third-generation Hispanics, reliance upon this system would depend upon the person's

self-directed or group-oriented problem solving and coping strategies (Keefe et al., 1979).

In their investigation of suburban Mexican Americans in Southern California, Griffith

and Villavicencio (1985) found that more acculturated (English-speaking) Mexican

Americans, when compared with less acculturated (Spanish-speaking) Mexican

Americans, relied less on their extended family network despite having larger numbers of

persons in the network who could be relied upon. Whereas the less acculturated Mexican

Americans relied most on available primary and extended family for emotional support,

the more acculturated Mexican Americans sought help from friends, neighbors, clergy

and church members (Cervantes & Castro, 1985). These findings support the general

view that, with greater acculturation, Hispanic Americans may develop large social

networks, yet they become less dependent upon members of their extended kinships for

social support. However, in the case of recent U.S. immigrants, they may often have

fewer friends or family members in the U.S., thereby facing increased risk for mental

health problems and difficulties accessing health care necessary for proper management

of chronic illnesses, such as heart disease.









Social Support and CHD

The presence of social support has been suggested to offer a protective effect with

respect to coronary heart disease (CHD) morbidity and mortality through increased

adherence to medical therapies and lifestyle recommendations, and mitigating the

potentially damaging effect of negative emotional interactions (Krumholz et al., 1998).

Several large-scale epidemiologic studies have found significant associations between

low levels of social support and increased cardiovascular mortality (Berkman & Syme,

1979; Blazer, 1982; House et al., 1988). Other studies have reported low levels of social

support to be related to various manifestations of CHD, including higher prevalence rates

of angina pectoris (Medalie & Goldbourt, 1976), myocardial infarction (Case et al., 1992;

Ruberman et al., 1984), and cardiac death (Krumholz et al., 1998). Based on this

evidence, some researchers have begun to examine whether social relationships improve

health by modifying health-related behaviors and physiological processes (Cohen, 1988).

There are a number of possible mechanisms responsible for these observed

effects. Positive social influences might be particularly beneficial during times of stress,

when people abandon healthy habits (e.g., diet, exercise, health monitoring) and engage

in risky behaviors (e.g., excessive consumption of nicotine, alcohol, or narcotics), by

providing positive health role models and reinforcing healthy behaviors, thereby

preventing health problems (Umberson, 1987). These associations do not appear to be

due to factors such as age, SES, or race (Forster & Stoller, 1992; Hanson et al., 1990;

Orth-Gomer et al., 1993). In addition, behavioral or traditional risk factors (e.g., smoking

habits, body mass, physical disability, cholesterol) alone do not appear to explain these

results (House et al., 1988).









Social Support and Depression

Social support has also been suggested to provide a buffering effect in the

manifestation of depression. For example, Briones and colleagues (1990) found direct

associations between levels of stress and depression and between support networks and

depression, such that individuals with more life stressors had higher rates of depression;

however, support networks were found to mitigate the influence of stress by decreasing

rates of depression. In addition, investigators have begun to examine low social support

as an additional determinant of depression after hospitalization for CHD (Holohan et al.,

1995, 1997; Oxman et al., 1994; Shumaker & Czajkowski, 1994; Yates, 1995). For

example, Oxman and Hull (1997) found that perceived adequacy of support one month

after surgery was associated with less depression at six months in a sample of elderly

CHD patients. The clinical implications of these findings are enhanced by results

indicating that both depression (Barefoot, 1997; Frasure-Smith et al., 1993) and social

support (Berkman, 1995; Orth-Gomer et al., 1988; Ruberman et al., 1984; Williams et al.,

1992) are repeatedly shown to predict survival in CHD patients. There are two possible

mechanisms to explain their additive effects. Specifically, these psychosocial risk factors

have been linked to increased sympathetic nervous system arousal (Williams & Littman,

1996) and an increase in health-damaging behaviors (e.g., smoking) that could have an

impact on prognosis, particularly increasing the risk for those individuals possessing one

or more of these psychosocial risk factors (Barefoot et al., 1995; Kaplan, 1995; Williams

et al., 1997).









Familism

Familism is considered to be one of the most important culture-specific values of

Hispanics. Multiple investigators have emphasized the significance of the family as a

major source of identity, self-worth, and social support for most Hispanic Americans

(Aranda & Knight, 1997; Cervantes & Castro, 1985). The importance of the centrality of

the family (nuclear and extended) in terms of having strong feelings of loyalty,

reciprocity, solidarity and attachment among members has been documented as a distinct

and enduring characteristic among several Hispanic subgroups (Cortes, 1995; Marin,

1993; Sabogal et al., 1987). To date, the concept of familism has been operationalized to

represent at least two different dimensions: attitudes and behavior (Marin, 1993;

Rodriguez & Kosloski, 1998). The attitudinal aspect includes the beliefs and attitudes

Hispanics share regarding the family and their feelings of loyalty and solidarity. The

behavioral component focuses on the specific behaviors associated with those feelings.

Familism among Hispanics has been proposed as a possible explanation for ease

of adaptation for some immigrants coming to the U.S., as well as for the relatively better

mental health profile of Hispanics as compared to non-Hispanic populations (Keefe,

Padilla, & Carlos, 1979). The Hispanic family has been described as an emotional

support system in which members can find help on a regular basis and are protected from

external physical and emotional stressors, thereby facilitating healthy psychological

adjustment (Cohen, 1979; Valle & Martinez, 1980).

Although the importance of familism is evident, various authors have proposed

that familism and other central Hispanic values are changing due to acculturation,

urbanization, migration, and increasing contact with the U.S. mainstream culture (Cuellar









et al., 1995; Garza & Gallegos, 1985; Rodriguez & Kosloski, 1998). For example,

Sabogal and colleagues (1987) investigated various dimensions of familism and

acculturation among three subgroups of Hispanics (Mexican-, Cuban-, and Central-

Americans). Despite differences in the national origin of Hispanics, subjects reported

similar attitudes toward the family indicating that familism is a core characteristic in the

Hispanic culture. In addition, three basic dimensions of familism were found: familial

obligations, perceived support from the family, and family as referents. Of these three

dimensions, familial obligations and the perceptions of the family as referents appeared

to diminish with higher levels of acculturation; however, the perception of family support

was not affected across acculturation levels, suggesting that perceived family support is

the most distinctive and stable dimension of Hispanic familism.

Together, these findings suggest that social support serves as a "protective buffer"

in the stress-illness paradigm, particularly with respect to CHD, depression, and ease of

cultural adaptation. Additionally, although low social support has been identified as an

independent risk factor for poor prognosis in patients with CHD, the additive effects of

depression and low social support can place the individual manifesting both these

psychosocial risk factors at increased risk for cardiovascular morbidity and mortality.

Finally, social support in Hispanics has been extensively studied through the cultural

construct of familism examining its role as a source of ethnic identity and social support

on mental health outcomes and cultural adaptation. Although aspects of this core value

have been shown to vary across levels of acculturation, it is a potentially valuable

construct in examining physical and mental health functioning in Hispanics with heart









disease, serving an adaptive role in cardiac patient adjustment and various dimensions of

quality of life.

Health-Related Quality of Life

Health-related quality of life (HQOL) is a multidimensional concept that

characterizes an individual's entire well being and includes psychological, social, and

physical dimensions (Aaronson, 1988). Assessments of HQOL help characterize the

psychosocial functioning and day-to-day experiences of patients with chronic medical

conditions or those recovering from invasive medical procedures. The patient profiles

obtained along these multiple dimensions can then be compared across different disease,

gender, ethnic, and sociodemographic groups. Therefore, psychosocial profiles of

different patient groups and subgroups allow for a better understanding of the effects a

disease has on daily functioning and psychosocial adjustment. Data on moderators of

HQOL, such as social support, personality characteristics, and sociocultural influences,

can be used to identify psychosocial factors that are associated with more favorable

HQOL profiles. This information potentially can be used by researchers to test the

effects of interventions or to enhance psychosocial adjustment for those living with

chronic medical conditions, such as coronary heart disease, by illustrating the daily

challenges and psychosocial issues faced by these patients. Finally, health care providers

may use the information to select treatment options that address clinical and psychosocial

needs of specific patient groups. The following sections review factors associated with

patients' psychological adjustment to their heart disease, as well as the role of

acculturation in the psychosocial functioning and health status of Hispanic populations.









Psychosocial Adjustment to Heart Disease.

Psychologically, as well as physiologically, the heart is crucial to one's identity

and social function. It is not surprising, therefore, that normal, emotional reactions to the

development of heart disease often include aspects of shock, fear, anger, guilt, sadness,

and grief. The onset of cardiac illness comes as an injury that can affect one's self-

esteem from many perspectives. Many patients are forced to confront issues of

dependence on others and loss of control, as well as face a less contributing role in

support of their families (Shapiro, 1996). In addition, sexual functioning may be

adversely affected by circulatory impairment, ischemia, medication, or by fear and other

emotional factors, contributing to a further loss of self-esteem that in turn may exacerbate

further decline and complicate adjustment and recovery (Quadagno et al., 1995). Finally,

the issues of progression of disease, recurrence of acute illness, and death are universally

present for heart disease patients and may be met with reactions ranging from denial to

adverse psychological sequelae, such as anxiety or depression (Brummett et al., 1998;

Kubzanksy et al., 1998; Littman, 1993).

For men and women who survive CHD events, the physical and psychosocial

sequelae of CHD can be significant, requiring long periods of recovery and, in some

cases, resulting in long-term functional, social, and emotional deficits. HQOL data from

NHLBI studies have highlighted the existence of gender-specific psychosocial profiles

for CHD patients, with women showing poorer psychosocial functioning than men even

after controlling for age, severity of disease, and comorbidities (Shumaker & Czajkowski,

1993). These findings suggest that disparities in psychosocial functioning may be related

to gender differences in societal role functioning (i.e., women are more likely to be









caregivers and may experience multiple role demands to a greater extent than men, which

may result in greater stress and poorer functioning). Data also suggest that healthy

women are more likely to be depressed than men (Nolen-Hoeksema, 1990), and social

isolation may be a more common experience for women, especially elderly women, given

their relatively longer lifespans (Berkman, Vaccarino, & Seeman, 1993).

Given the complicated nature of heart disease and its debilitating impact on areas

of physical and psychosocial functioning, studies have attempted to identify

sociodemographic, psychological, and cultural factors that influence health outcomes in

this patient population (Kinney et al., 1996). Socioeconomic status (SES) has been

demonstrated to be one of the most robust predictors of mortality and disease progression

in patients with CHD (Marmot & Smith, 1997; Williams et al., 1992), as well as for both

behavioral and subjective measures of health and well being (Chamberlain, 1997;

Marmot et al., 1991). A strong association with all-cause mortality has been observed

regardless of whether SES is measured in terms of occupation, income, or education

(Adler et al., 1994; Carroll et al., 1996), and this association has been demonstrated for

women as well as men (Ginn & Arber, 1989). Mechanisms for this relationship include

CHD risk-developing lifestyle, inadequate access to services or health education, low

social support, high levels of stress, and inadequate coping skills (Rodriguez, 1996). In

Hispanic populations, an important correlate of SES, acculturation, is frequently

unaccounted for in many studies examining health status and psychosocial functioning.

A significant positive relationship has been demonstrated between acculturation level and

SES, suggesting that highly acculturated individuals come from backgrounds with higher

standards of living and better education (Negy & Woods, 1992). However, it remains









unclear whether being more acculturated facilitates integration into the mainstream

culture, which could result in better living standards and education, or whether higher

SES facilitates becoming more acculturated. It is also likely that these two possibilities

are simultaneously influential. Despite evidence linking economic and cultural factors to

disease progression, few studies have focused on identifying the underlying

psychological, social, and structural processes that account for these relationships.

Acculturation and Health-Related Quality of Life

Limited research has compared the well being and functioning of patients from

different ethnic backgrounds with chronic medical conditions. Given that ethnic

differences in attitudes, beliefs, and behavior have been reported on health-related issues

such as cigarette smoking (Marin et al., 1990), cancer (Perez-Stable et al., 1992, 1994),

self-rated health status, and well being, other outcomes may also differ by ethnicity

through different dimensions of acculturation. Previous research among Hispanic groups

has suggested that self-rated health status is related to acculturation, income, language

proficiency, and years residing in the U.S. (Angel & Angel, 1992; Markides & Lee, 1991;

Seijo et al., 1991). Therefore, studies examining the relationship between ethnicity and

acculturation on self-rated health and global functioning are important in light of their

influence on medical management of disease, utilization of health care resources, and

health outcomes.

The first researcher to conduct a study specifically designed to investigate the

relationship between acculturation and functional capacity was Ailinger (1989). In this

study, 152 elderly Hispanic immigrants were administered the Multidimensional

Functional Assessment Questionnaire (MFAQ; George & Fillenbaum, 1985), which was









designed to assess the functional status of elderly adults on five dimensions: social,

economic, mental health, physical health, and activities of daily living (ADL).

Acculturation was estimated by years of residence in the U.S. Results indicated that of

the five functional areas, social functioning (54%) and economic resources (73%) were

the most impaired. As education increased, social and economic functioning improved,

as did mental health. Longer residence in the U.S. was related to better economic

resources (r = -.52, p <.001) and higher cumulative functional scores (r = -.29, p <.001).

In a 5-year follow-up of this subject sample (n = 76; Ailinger et al., 1993), years of

residence in the U.S. remained related to economic resources (r = .34, <.05). In

general, functional ratings assessed at Time 1 were the strongest predictors of 5-year

follow-up ratings. The authors concluded that the Hispanic immigrant sample under

study was functioning well in the community without much change in their status over

time. In terms of acculturation, this sample had been residing in the U.S. an average of

14 years at 5-year follow-up, indicating that they had immigrated from their homeland

while in their 50s and still able to work. The authors suggested that this group was more

likely to remain in a stable state over time, given that they had been able to deal with the

adjustment of a major relocation during middle age. However, it is important to take into

account that the sample at Time 2 was of survivors only, a group who by definition has

certain strengths.

Health status and acculturation were also investigated in a large sample (n =

1012) of Hispanic and non-Hispanic white adults (Shetterly et al., 1996). In this study,

participants rated their health on a continuous scale of "excellent" to "poor," and

completed a self-constructed measure of acculturation consisting of English proficiency,









circle of friends, and value orientation. In general, no large ethnic differences were

observed in factors that influence self-reported health (e.g., illness, medications,

hospitalizations). However, Hispanics (both mono- and bilingual) were 2.2 times more

likely than non-Hispanic whites to report fair or poor health, even after controlling for

socioeconomic factors. In addition, highly acculturated Hispanics rated their health

similarly to non-Hispanic whites, while low acculturated Hispanics remained two to three

times more likely to report fair or poor health compared to non-Hispanic whites. These

researchers concluded that, as a group, traditionally oriented Hispanics may have

reported lower health ratings due to the experience of somatic symptoms that may not

have been fully captured by their measures of physical illness or affect.

Tran and colleagues (1996) conducted a path analysis to investigate the

relationship of acculturation, stress, health status, and psychological distress among

elderly Hispanics. Their study consisted of a national-area probability sample of

Mexican-American, Puerto Rican, and Cuban elderly (n = 2019). Participants completed

Bradburn's affect balance scale and measures of social and family/personal stress, self-

reported health status, and physical limitations to examine physical and emotional

adjustment patterns within this population. Education and English proficiency served as

indicators of acculturation. The overall model explained 29% of the total variance in

psychological distress. Acculturation had a significant effect upon health status, such that

less acculturated respondents (i.e., low levels of education and English proficiency) were

found to experience higher rates of self-reported health problems compared to those with

higher levels of acculturation (education, DE = .09; English proficiency, DE = -.10;









p <.05). The findings also suggest that the existence of health problems contributed, both

directly and indirectly, to higher levels of stress and psychological distress. One

interpretation provided by the authors is that those elderly Hispanics who are less

acculturated tend to experience difficulties in accessing health care because they have

fewer language skills and lower levels of education. The lack of access to medical care

may lead, in turn, to their tendency to perceive themselves as subject to certain health-

related problems. This interpretation is supported by a previous study, which found that

language barriers and lack of education were associated with difficulties in accessing

medical care (Siddharthan & Sowers-Hoag, 1989).

In a more recent study, Perez-Stable, Napoles-Springer, and Miramontes (1997)

examined 226 Hispanic and non-Hispanic white patients with hypertension or diabetes to

compare the effect of ethnicity and language concordance with their physician on health

outcome measures, use of health-care services, and clinical outcomes. Patients

completed the SF-36 and a general measure of health-care satisfaction in order to

examine the association between ethnicity and language concordance on perceived

physical and emotional well being and health-care satisfaction. Among the 73 (66%)

Hispanics who responded in Spanish, 44 (60%) were followed by clinicians who spoke

Spanish (language concordant), and 29 (40%) were followed by non-Spanish speaking

clinicians (language discordant). Results indicated that Hispanic patients reported a

better health outlook (D = 10.3, p <.01), less health distress (D = -9.0, p <.05), and fewer

days interfered with by pain (D = -14.1, p <.05) than non-Hispanic white patients. In

addition, having a language concordant physician was associated with higher perceived

physical functioning (R2 = .32, p <.05), better psychological well-being (R2 = .20, p









<.01), better overall perceptions of health (R2 = .26, p <.05), and less pain interference in

daily activities (R2 = .23, p <.05). These results are consistent with other studies showing

language concordance between patient and physician to be associated with increased

compliance (Manson, 1988), greater patient-physician communication (Seijo et al.,

1991), and better patient care (Todd et al., 1993).

Methodological Critique

In review, these four studies offer evidence to suggest that the process of

acculturation influences psychosocial adjustment and health-related quality of life in

Hispanic populations. However, the literature related to patient adjustment is clearly in

its beginning stages, and appears to have only just begun to emerge over the last decade.

Consequently, many methodological flaws currently exist in the literature. Of primary

importance, most of the research conducted in this area has been limited in the manner

that acculturation is operationalized. For example, three of the four studies reviewed

utilized behavioral indices of acculturation (i.e., language proficiency, length of U.S.

residency, education) to best estimate the influence of cultural adaptation on perceived

health status (Ailinger, 1989; Perez-Stable et al., 1997; Tran et al., 1996). The inherent

problem in this approach to measurement is that these proxy measures of acculturation

exclude cognitive components, such as cultural values and belief systems, which are

highly important and representative of acculturative change. In addition, these proxy

measures are largely used as criterion variables in the validation of developed

acculturation scales. Therefore, problems arise when validation criteria are used as

measures rather than as correlates of acculturation (Marin, 1992). As discussed earlier,

when a single index of acculturation is utilized to capture aspects of a multidimensional









construct, individuals are often misclassified. For example, recent Hispanic immigrants

may have high levels of education although their level of acculturation is relatively low.

The literature has also been enveloped with the use of non-standardized

assessment measures of functional status and inconsistent operationalization of

psychosocial constructs. Two of the studies reviewed (Shetterly et al., 1996; Tran et al.,

1996) relied upon single-item measures to make conclusions regarding patient

functioning, rendering results more difficult to interpret meaningfully. Studies such as

these may provide a narrow, perhaps inaccurate picture on the psychosocial adjustment

and quality of life of Hispanic populations as they are designed to measure only a single

aspect of health status (Chwalow, 1995). Another serious problem with the literature has

been the limited attempt of these studies to control for disease severity on outcomes of

perceived physical and psychosocial functioning. Disease severity has been empirically

shown to influence differences in utilization of health care services, mortality rates, and

functional status outcomes (Greenfield et al., 1995). Consequently, two studies

attempted to control for physical health status through subject reports of chronic illness,

prescription medications, and hospitalizations (Ailinger, 1989; Shetterly, 1996); however,

multimodal indicators of health status (e.g., physician rating, physiological markers)

would more adequately address the inherent problem of relying solely on self-report

methodology. To date, there have been few studies examining the relationship of

acculturation and health outcomes in chronically ill patient populations, particularly heart

disease (Perez-Stable et al., 1997). As such, inferences about the unique impact that the

acculturation process has on the psychosocial functioning of Hispanic patients with heart

disease are limited. Further, the additive effects of psychological and social factors may









result in strong associations with acculturation on the perceived health status and

functioning of Hispanic populations, particularly when combined with other influencing

factors common to medically-ill patient populations (e.g., co-morbid medical diagnoses,

declines in general health).

In summary of the literature to date, the following conclusions can be made: (1)

investigators in the field of HQOL research have only begun to systematically examine

the unique nature of acculturation in relation to the psychological adjustment of Hispanic

patients with chronic medical illnesses; (2) studies examining various health indices have

demonstrated a strong positive relationship with acculturation, independent of ethnicity

and socioeconomic factors, such that highly acculturated individuals report higher overall

functioning; (3) prospective studies of self-rated health demonstrate no change in

functional status over time; and (4) the majority of existing research contains serious

methodological limitations, such as subject selection biases, poor control of medical

variables, and the use of non-standardized assessment measures, accentuating the need

for more culturally sensitive and comprehensive assessments in Hispanic patient

populations.

Aims of the Current Study

Given the chronic and debilitating nature of coronary heart disease (CHD), it is

not surprising that some individuals experience difficulties in adjustment as well as

psychological complications secondary to their medical condition. Psychosocial factors,

such as depression and social isolation, have been empirically related to the development,

clinical expression, and prognosis of CHD. However, most of these studies have been

conducted with primarily Anglo-American samples, despite evidence demonstrating high









mortality from CHD and increased prevalence of both traditional and psychosocial risk

factors in Hispanic populations.

Recent studies have attempted to characterize the daily functioning and

psychosocial adjustment of Hispanics residing in the U.S. by examining the manner by

which acculturation, or level of cultural integration, influences quality of life outcomes.

Acculturation may impact Hispanic heart disease patients through its influence on

patient-physician communication, reliance on family support systems, health care

utilization, passive or fatalistic interpretations of illness, and disease prognosis via

depression and social support. However, to date, culturally sensitive and theoretically

based studies assessing Hispanic patient adjustment to CHD are nonexistent.

In response to these deficits in the CHD literature, the current investigation seeks

to examine the psychosocial adjustment of Hispanic cardiac patients. The current study

has the following objectives: 1) report the incidence of depression, degree of social

support and cardiac-related quality of life (CQOL) in this patient population; 2) examine

factors unique to Hispanic culture (i.e., acculturation, familism, fatalism); and 3)

investigate these psychosocial and cultural dimensions as predictors on three specific

domains of cardiac patient functioning (i.e., physical, emotional, social), while

controlling for age, gender, SES, medical severity, and time since cardiac diagnosis.

Hypotheses

The following hypotheses are made about the predictive models tested: 1) It is

expected that women, cardiac patients with a lower SES, who are presenting with high

levels of medical severity, depressive symptomatology, and fatalistic beliefs will display

lower levels of physical, emotional, and social functioning; and 2) older Hispanic cardiac






33


patients, who have lived with their cardiac diagnosis for a long period of time, and

presenting with high levels of social support, acculturation, and familism will display

higher levels of physical, emotional, and social functioning. These study findings are

expected to help health care providers and family members identify common patterns of

psychosocial adjustment and factors associated with more favorable quality of life

outcomes in Hispanic cardiac patients.
















METHOD

Participants

One hundred and thirty Hispanic cardiac patients visiting a cardiology clinic in

south Florida were approached for this study. Subject involvement was voluntary and no

compensation was offered for their participation. In order to be admitted into the study,

participants were required to meet the following inclusion criteria: 1) be at least 18 years

of age, and 2) have a primary diagnosis of coronary heart disease, consisting of coronary

artery disease (CAD) with or without cardiomyopathy. Following their appointment with

the cardiologist, patients were asked to participate in a brief clinical interview consisting of

several assessment measures. The clinical interview materials were presented to

participants in either English or Spanish, based on patient preference. Participants were

told that all responses would be confidential and to ensure anonymity, subject numbers

were used to identify each patient's responses. The Institutional Review Board (IRB) at

the University of Florida Health Science Center approved this study and all procedures

for ethical research were followed.

Of the 130 patients approached for the study, 10 (7.7%) declined to participate,

resulting in a total sample size of 120. Non-participants were not significantly different

from study participants in relation to age or gender. Of the 120 participants, the majority

were male (70.8%), with a mean age of 65.9 years (range 37 to 91), covered under some

form of health insurance (99.2%), and having had an 8th grade education or less (42.5%).









The sample was predominantly Cuban-American (71.7%), Catholic (85.8%), and married

(71.7%), with 43.4% of participants having retired from their previous employment and

residing in the U.S. an average of 28.1 years (SD = 13.9). One hundred percent of

participants requested that the clinical interview be conducted in Spanish and 75.0%

identified themselves as "Purely Hispanic" on a one-item Ethnic Identity Scale.

Participants reported delaying the use of health care services an average of 28.8

days (SD = 99.1) after first noticing symptoms related to their heart disease and visiting

their doctor an average of 4.4 times in the past six months (SD = 4.1). The majority of

Hispanic cardiac patients had a primary diagnosis of coronary artery disease (64.2%), a

New York Heart Association (NYHA) class II (54.8%) with a mean left ventricular

ejection fraction (LVEF) of 45.7% (range 15 to 70), and averaged 5.7 years (range 1

month to 27 years) since the time of their initial diagnosis. In addition to LVEF, Hurst

and colleagues (1999) have recommended that the NYHA's classification of

cardiovascular disease be utilized as an index of medical severity to comprehensively

examine the nature and course of one's heart disease. NYHA class takes into account the

etiology, anatomy, physiology, functional classification, and objective assessment for

each patient. Therefore, LVEF and NYHA class will also be analyzed for comparison

purposes. Descriptive statistics for demographic data are presented in Table 1.

Cardiac Risk Factor Profile

Table 2 presents the cardiovascular risk factor profile for the current study sample

of Hispanic cardiac patients. The sample was predominantly sedentary, with 45.8%

reporting no exercise activity. Further, 64.2% of patients were either current or past

smokers. The majority of study participants had a history of hypertension (77%),









valvular heart disease (51.3%), angina (95.8%), and hypercholesterolemia (57.1%). In

addition, a large proportion of patients had experienced a myocardial infarction (52.5%),

arrhythmia (48.3%), and were diagnosed with diabetes mellitus (30.2%).

Measures

During patient assessment, the following instruments were administered:

(1) Background Questionnaire (see Appendix A), (2) Center for Epidemiological Studies-

Depression (see Appendix B), (3) Familism Scale (see Appendix C), (4) Fatalism -

Mastery Scale (see Appendix D), (5) MacNew Quality of Life After Myocardial

Infarction Questionnaire (see Appendix E), (6) Medical Outcomes Study Social

Support Survey (see Appendix F), and (7) Short Acculturation Scale for Hispanics (see

Appendix G). The Spanish-versions of these measures have been translated and utilized in

prior studies examining Hispanic populations. Presented below, in alphabetical order, is a

detailed description of each of the primary assessment measures that were administered

in the current study.

Background Questionnaire

A custom designed questionnaire was used to gather demographic information on

all study participants, including age, sex, socioeconomic status, Hispanic background,

years residing in the U.S., and ethnic identity. Socioeconomic status (SES) was

calculated utilizing the four-factor Hollingshead index (Hollingshead, 1975). In addition,

this questionnaire contains specific information related to health status, risk factors for

heart disease (i.e., exercise, smoking, and drinking patterns), and health care utilization.

Information related to each patient's cardiac history (e.g., NYHA class, LVEF, cardiac

risk factors) was collected from his or her available medical records.








Table 1

Demographic characteristics of study participants


Characteristic n % Characteristic n % Characteristic n %


Age
Under 55
55-64
65-74
75 and above


Gender
Male
Female
Religion
Catholic
Christian
Other

Marital Status
Single/Never Married
Separated
Married

Divorced

Widowed


Education
8th grade or less
Some high school
HS graduate / GED
Some college
College graduate
Post-graduate work


15.8
33.3
24.2
26.7



70.8
29.2

85.8
6.7
7.5


4.2
5.0
71.7


11 9.2

12 10.0


42.5
7.5
15.8
21.7
8.3
4.2


Employment Status
Employed full-time
Employed part-time
Not employed
Retired
Medically Disabled
SES Categories
Unskilled Laborers
Semiskilled Workers
Skilled Craftsmen
Minor Professional
Major Professional


Ethnic Identity
Purely Hispanic
Somewhat Hispanic
Partly Hispanic &
Anglo-American
Somewhat Anglo-
American
Purely Anglo-
American
Ethnicity
Puerto Rican
Cuban
South American
Central American
Other Hispanic
Mixed


30.8
4.2
7.5
43.3
14.2


26.1
31.9
17.6
19.3
5.0



75.0
10.0
11.7


1 0.8

3 2.5


7.5
71.7
11.7
5.8
1.7
1.7


Cardiac Diagnosis
CAD
CAD & Cardiomyopathy
CAD & CHF
CAD, Cardiomyopathy, CHF


Years Since Diagnosis
1 year or less
2 4 years
5 9 years
10 or more years



Ejection Fraction
30% or less
31 40%
41 50%

51 60%

> 60%


NYHA Class
Class I
Class II
Class III


64.2
30.8
3.3
1.7



21.7
35.0
16.7
26.7




12.7
22.9
32.2


32 27.1


5.1



20.9
54.8
24.3








Table 2

Cardiovascular risk factor profile of study participants


Factor n %0 Factor n % IFactor n % Factor n %


Exercise Frequency
> Once a day 3 2.5
4-7 times/week 36 30.0
1-4 times/week 21 17.5
1-2 times/month 5 4.2
Never 55 45.8


Family Hx of CAD
Yes
No
Diabetes
Yes
No
Hypertension
Yes
No
MI History
Yes
No


41 36.9
70 63.1


35 30.2
81 69.8


87 77.0
26 23.0


63 52.5
57 47.5


Exercise Intensity
Extremely Vigorous 4 3.3
Somewhat Vigorous 23 19.2
Not Very Vigorous 35 29.2
Not Applicable 58 48.3


Vascular Disease


Yes
No


Arrythmia
Yes
No


Valvular Disease
Yes
No


Angina
Yes
No


Smoking History
Current Smoker 13 10.8
Past Smoker 64 53.4
None 43 35.8



Previous Stent


14 11.8 Yes
105 88.2 No


58 48.3
62 51.7


60 51.3
57 48.7


113 95.8
5 4.2


Previous PTCA
Yes
No


Pacemaker
Yes
No


Bypass Surgery
Yes
No


30 25.0
90 75.0


40 33.3
80 66.7


12 10.0
108 90.0


40 33.3
80 66.7


Age Risk
Male > 45
Female > 55
None



LDL > 130
Yes
No


HDL< 35
Yes
No


High Cholesterol
Yes
No


82 68.3
29 24.2
9 7.5




21 21.6
76 78.4


16 16.7
80 83.3


68 57.1
51 42.9









Center for Epidemiologic Studies-Depression Scale (CES-D: Radloff, 1977)

The CES-D is a 20-item, self-report questionnaire containing several of the common

affective and somatic symptoms of depression. The respondent is asked how often he/she has

experienced these symptoms during the past week, ranging from 0 (less than 1 day) to 3 (5-7

days). The total possible score ranging from 0 to 60 reflects both the number of symptoms

reported and their duration. Higher scores reflect greater severity of depressive symptomatology.

A cut-off score of 16 is used for the initial screening for a possible diagnosis of a depressive

disorder. However, a cut-off score of 27 has also been suggested to provide the optimal

combination of sensitivity and specificity to detect depressive symptoms in medical populations.

Consequently, 16 was used as the standard cut-off score and 27 as the stringent cut-off score for

this study. This questionnaire is designed to be an epidemiologic instrument to measure the

degree of depressive affect in community samples; it does not provide a diagnostic criterion for

depression. The CES-D has demonstrated adequate internal consistency and test-retest reliability

in general populations (Radloff, 1977; Radloff & Locke, 1986; Weissman et al., 1977) as well as

in Mexican-American, Puerto Rican, and Cuban-American populations (Guarnaccia et al., 1989).

Cronbach's alpha for the current study was .89 and is consistent with previous estimates (Zich,

Attkisson, & Greenfield, 1990).

Familism Scale (Familism: Sabogal, Marin, & Otero-Sabogal, 1987)

The Familism scale is a 13-item, self-report measure comprised of three factors: (1)

Familial Obligations (respondents' perceived obligation to provide material and emotional

support to the members of the extended family), (2) Perceived Support from the Family

(perception of family members as reliable providers of help and support to solve problems), and

(3) Family as Referents (deals with relatives as behavioral and attitudinal referents). Familism









items were taken from the Familism scales developed by Bardis (1959) and by Triandis et al.

(1982). Respondents are instructed to answer each of the 13 questions on a five-point Likert-

type scale (with 5 indicating "Completely True" and 1 "Not at all True"). For the purposes of

the present study, the total score across these factors was utilized. Higher scores on the familism

scale indicate more traditional views of the family as a support system. Cronbach's alpha for the

current sample was .80.

Fatalism/Mastery Scale (Fatalism: Neff & Hoppe, 1993)

The Fatalism/Mastery Scale is a seven-item measure of "Personal Fatalism" (the

individual's perception of his or her ability to control events in the world) developed from items

used by Chandler (1979) and by Pearlin and Schooler (1978). Responses to each of the seven

items range from 1 (Strongly agree) to 4 (Strongly disagree). Lower scores are an indicator of

having fatalistic interpretations towards future events and a sense of low mastery. Internal

consistency reliabilities have been demonstrated to be .70, .76, and .80 in Anglo Americans,

African Americans, and Mexican Americans, respectively. The Cronbach's alpha for the

fatalism/mastery scale in the current study was .63.

MacNew Quality of Life after Myocardial Infarction Questionnaire (QLMI: Valenti, Lim,
Heller, & Knapp, 1996)

The QLMI is a 27-item cardiac disease-specific quality of life questionnaire. The QLMI

addresses three major dimensions of cardiac-related quality of life (CQOL): Emotional, Physical,

and Social functioning. Statistically significant correlations between the QLMI and other health-

related quality of life (HQOL) measures, as well as moderate to strong evidence for the

measure's predictive and discriminative validity have been demonstrated in cardiac patient

populations (Oldridge et al., 1991; Hillers et al., 1994). Several investigators have suggested that

disease-specific instruments, which focus on the problems of a defined medical population, are









preferable over generic HQOL measures due to their sensitivity in capturing aspects of specific

medical illnesses (Dempster & Donnelly, 2000; Guyatt et al., 1989; Hillers et al., 1994). Higher

scores on the physical, emotional, and social dimensions from the QLMI indicate better health

status in that domain. The Cronbach's alpha for the QLMI dimensions in our study were .86

(Physical), .87 (Emotional), and .82 (Social), respectively. A single global index of CQOL may

also be derived by combining the patient's responses to all items on the QLMI.

MOS Social Support Survey (MOS-SS: Sherbourne & Stewart, 1991)

The MOS-SS is a 19-item, self-report survey of functional social support that represents

five dimensions: (1) Emotional support (the expression of positive affect, empathetic

understanding, and the encouragement of expressions of feelings), (2) Informational support (the

offering of advice, information, guidance or feedback), (3) Tangible support (the provision of

material aid or behavioral assistance), (4) Positive Social Interaction (the availability of other

persons to do fun things with you), and (5) Affectionate support (involving expressions of love

and affection). Subjects rate their perceptions of the availability of different functional aspects

of support (e.g., the degree to which their interpersonal relationships serve particular functions).

The MOS-SS has been shown to have strong internal consistency (.91 to .97) and has

demonstrated high convergent and discriminant validity of items, supporting the dimensionality

of the measure (Sherbourne & Stewart, 1991). Although each of these scales can be interpreted

separately, the literature indicates that the scores on the MOS-SS scales can also be summed to

derive a single, valid indicator of perceived availability of social support. For the purposes of

this study, this approach was taken and only the total MOS-SS score was utilized in the planned

analyses. Higher scores reflect a greater degree of perceived social support. Cronbach's alpha

for the total score in the current study was .95.









Short Acculturation Scale for Hispanics (SASH: Marin, Sabogal, VanOss-Marin, Otero-

Sabogal, & Perez-Stable, 1987)

The SASH is a 12-item, self-report measure of behavioral acculturation for Hispanics.

Separate factor analyses of 363 Hispanics and 228 non-Hispanic whites have produced three

factors: (1) Language Use, (2) Media, and (3) Ethnic Social Relations. These three factors have

been shown to have moderate to high internal consistency, with alpha coefficients ranging from

.78 to .90, with an overall internal consistency coefficient of .92. The SASH has been

demonstrated to correlate highly with the following validation criteria: respondents' generation,

length of residence in the U.S., age at arrival, ethnic self-identification, and with an acculturation

index (Marin et al., 1987). Non-Hispanics have also been shown to differ significantly from

Hispanics in their responses to the SASH. Although each of these factors can be interpreted

separately, a single, valid indicator of acculturation can be derived. For the purposes of this

study, this approach was taken and only the total SASH score was utilized in the planned

analyses. Higher total scores are an indicator of greater integration into the U.S. mainstream

culture. Respondents may also be placed in categories of "low acculturation" (< 3),

biculturalismm" (= 3), or "high acculturation"(> 4) based on their total scores. Cronbach's alpha

for the current sample was .89.















RESULTS

Incidence of Depression and Degree of Acculturation, Social Support, and CQOL

A categorization of depressed versus non-depressed Hispanic cardiac patients (cut-off

score > 16) indicated that 25.9% of our sample (n = 31) endorsed items reflecting significant

depressive symptomatology as measured by the CES-D. Furthermore, 9.2% (n = 11) met more

stringent criteria (cut-off score > 27) for depression. Regarding our cultural measures, 91.7% of

our sample (n = 110) met classification criteria for "low acculturation" (total score < 3) and 8.3%

(n = 10) for biculturalismm" (total score = 3) as measured by patient responses on the SASH.

None of our sample met criteria for "high acculturation" (total score > 4). In addition, 85.8% of

study participants perceived having a high degree of social support available to them (total score

> 70.83) as evident by their responses on the MOS-SS. Finally, although a majority of Hispanic

patients reported moderate to high cardiac-related quality of life (CQOL) 84.2% to 85.8% as

evident in their responses on the QLMI, there remained a subset of patients (one or more

standard deviations below the mean) that endorsed items indicative of adjustment difficulties in

the areas of physical (14.2%), emotional (14.2%), and social (15.8%) functioning, respectively.

Relationships between Quality of Life Dimensions and Cardiac Patient Study Variables

Table 3 presents the zero-order correlations for the predictor and outcome variables under

study. Consistent with prior studies, acculturation was moderately correlated to SES (r = .48, p <

.01), suggesting that the process of acculturation tends to be facilitated in those individuals who

come from backgrounds with greater economic resources and higher education. Acculturation









was also significantly related to age (r = -.35, p < .01) and familism (r = -.32, p < .01), suggesting

that older Hispanic patients in our sample tended to communicate primarily in Spanish and retain

traditional attitudes and behaviors related to the Hispanic family. LVEF and NYHA class were

inversely correlated as expected (r = -.34, p < .01), such that patients with a low ejection fraction

were classified at a higher NYHA medical severity level. Finally, results showed that

depression, as measured by the CES-D, was highly correlated with the emotional functioning

dimension of the QLMI (r = -.81, p < .01). Therefore, depression was not entered into the

multiple regression equation for emotional functioning due to its likely colinearity; however,

depression was entered for the dimensions of physical and social functioning.

Patient Characteristics Influencing Cardiac-Related Quality of Life

In order to determine the effect of age, gender, SES, LVEF, NYHA class, and time since

diagnosis on Hispanic patients' cardiac adjustment, a series of between subjects analyses of

variance (ANOVAs) were conducted. For all ANOVAs, the total score from the QLMI was used

as the dependent variable to assess CQOL. ANOVA analyses demonstrated a significant main

effect for gender, F(1, 119) = 10.71, p < .01; time since cardiac diagnosis, F(3, 119) = 2.68, p <

.10; and NYHA class, F(2, 114) = 14.66, p < .001, respectively.

Examination of group means indicated that females (M = 5.33, SD = 0.67) displayed

greater adjustment difficulties in relation to their heart disease than males (M = 5.86, SD = 0.86).

Further, post-hoc comparisons examining mean differences across levels of time since diagnosis

revealed that those patients with a diagnosis of coronary heart disease for 10 years or more

demonstrated greater adjustment difficulties than those diagnosed for 2 to 4 years, t(120) = 0.55,

p < .10 (see Figure 1). No other significant differences were observed for any of the remaining

time since diagnosis comparisons. Finally, post-hoc comparisons examining mean differences









across NYHA class indicated that as medical severity level increased, CQOL diminished. These

differences were noticeable between NYHA class I and III, t(115) = -1.02, p < .001; and NYHA

class II and III, t(115) = -.83, p < .001 (see Figure 2). Given that there were no significant

differences found for LVEF on cardiac patient adjustment, NYHA class replaced this variable as

an index of medical severity to assess the degree of unique variance contributed by its entry into

the three multiple regression models representing dimensions of CQOL.

Regression Models for Dimensions of Cardiac-Related Quality of Life

The three dimensions of CQOL (physical, emotional, and social functioning) were each

predicted through hierarchical multiple regression analyses (Table 4). Within each block

entered, a stepwise selection procedure was utilized to obtain the most efficient model (Figure 3).

For all regression analyses, predictor variables were entered in three separate steps. Step 1

entered five patient characteristics (i.e., age, gender, SES, NYHA class, time since diagnosis) as

a block followed by the two psychosocial measures (i.e., depression and social support) in the

second step to test the differential impact of each of these variables on dimensions of CQOL. As

previously mentioned, depression was not entered into the multiple regression equation for

emotional functioning due to its likely










Table 3


Correlations. Means.


and Standard Deviations of Study Variables


Variable
1. AGE
2. GEN
3. SES
4. LVEF
5. NYHA
6. TMDX
7. DEP
8. SS
9. ACC
10. FAM
11. FAT
12. PF
13. EF
14. SF
Note. GEN


4
-.05
.09
-.06


5
.13
.08
-.11
-.34**


6 7
.03 -.02
-.07 .24**
.04 -.16
-.24** .09
.19* .22*
.03


8 9
.08 -.35**
-.18* -.07
.01 .48**
-.00 -.05
-.08 -.03
-.01 .06
-.46** .05
-.11


10
.15
.10
-.39**
.06
-.01
-.04
-.02
.20*


11
-.11
.01
.03
-.15
-.20*
-.01
-.29**
-.00


-.32** .00
-.04


12
-.05
-.21*
.18
.06
-.45**
-.21*
-.64**
.26**
-.06
.01


.0'
-.3
.1L
-.1:
-.2
-.0'
-.8
.40
-.0(
.04


.22* .2:
.7,


13 14 M
7 -.12 65.9
1** -.10
4 .18* 29.8
3 .14 45.7
6** -.44** -
7 -.21* 5.7
1** -.59** 11.4
4** .16 88.1
6 .02 1.7
4 -.01 4.0
2* .14 18.9
4** .87** 5.6
.68** 5.8
5.9


= Gender; SES = Socioeconomic Status; LVEF = Left Ventricular Ejection Fraction; NYHA = New York Heart


Association Class YRDX = Time Since Diagnosis; DEP = Depression; SS = Social Support; ACC = Acculturation; FAM = Familism;

FAT = Fatalism; PF = Physical Functioning; EF = Emotional Functioning; SF = Social Functioning.


*p<.05. **p<.01.


SD
11.1

13.6
12.7

5.5
10.5
17.2
0.6
0.6
3.0
1.0
0.9
0.8


I I










6.1


6 -


5.9


o 5.8











5.4 -


5.3 -


5.2 -

5.1

1 year or less 2-4 years 5-9 years 10 or more
years

Time Since Diagnosis
lime Since Diagnosis


Figure 1. Mean Scores of Global Quality of Life by Time Since Cardiac Diagnosis







48


6.2



6



5.8



S5.6



c 5.4



5.2



5



4.8
NYHA Class I NYHA Class II NYHA Class III
NYHA Class


Figure 2. Mean Scores of Global Quality of Life by NYHA Class









colinearity. The three indices of acculturation (i.e., behavioral, familism, fatalism) were

then entered in the third step to examine the unique contribution of behavioral

acculturation, familism, and fatalism on dimensions of CQOL, while controlling for

patient characteristics and psychosocial variables.

Physical Functioning

As seen in Table 4, the gender of Hispanic cardiac patients significantly

accounted for 3% of the variance for scores on the QLMI Physical Functioning Scale.

NYHA class was also significant and added an additional 21% of the variance to the

model. Depression, as measured by the CES-D, accounted for the greatest increment in

variance for physical functioning, with an additional 28% explained by its entry into the

model, thereby increasing the overall variance accounted for by the final model to 52%.

However, none of the remaining patient characteristics (i.e., age, SES, time since

diagnosis), psychosocial variables (i.e., social support), or dimensions of acculturation

(i.e., behavioral, familism, fatalism) significantly contributed any additional variance to

QLMI Physical Functioning scores. These findings suggest that women, patients with a

higher degree of medical severity, and presence of depressive symptoms are each

predictive of lower perceived physical functioning among this sample of Hispanic cardiac

patients.

Emotional Functioning

As with physical functioning, NYHA class and gender of Hispanic cardiac

patients significantly predicted scores on the QLMI Emotional Functioning Scale,

accounting for 6% and 10% of the variance, respectfully (see Table 4). Fatalism

significantly accounted for 3% of the variance. Social support, as measured by the









Independent Variables


STEP I


Dependent Variables


Figure 3. Models for the Three Planned Regression Analyses


STEP II


STEP III


Control Variables

Age
Gender
SES
NYHA Class
Time Since Diagnosis


Psychological Variables

Social Support
Depression


Model 1

Physical Functioning

Model 2

Emotional Functioning

Model 3

Social Functioning


Cultural Variables

Acculturation
Familism
Fatalism









Table 4

Summary of Final Regression Analyses for Variables Predicting Three Dimensions of Cardiac-
Related Quality of Life, Depression, and Social Support


P R2 A R2
Physical Functioning .52
Depression -.56*** .28
NYHA Class -.32*** .21
Gender -.05 .03
Emotional Functioning .33
Social Support .39*** .14
Gender -.23** .10
NYHA Class -.18* .06
Fatalism .18* .03
Social Functioning .45
Depression -.52*** .26
NYHA Class -.32** .19
Depression .34
Social Support -.43*** .17
Fatalism -.27** .07
Gender .16* .06
NYHA Class .12 .04
Social Support .26
Depression -.44*** .18
Familism .20* .04
Gender -.10 .04
*p<.05. **p<.01. ***p<.001.









MOS-SS, was also significant and added an additional 14% of the variance, increasing

the overall variance accounted for by the final model to 33%. None of the remaining

patient characteristics (i.e., age, SES, time since diagnosis) or dimensions of acculturation

(i.e., behavioral, familism) significantly contributed any additional variance to QLMI

Emotional Functioning scores. These findings suggest that women, those with a higher

degree of medical severity, as well as those patients with low levels of social support and

low mastery (i.e., fatalism) were associated with lower levels of perceived emotional

functioning.

Social Functioning

NYHA class significantly accounted for 19% of the variance for scores on the

QLMI Social Functioning Scale. As with physical functioning, depression accounted for

the greatest increment in variance for social functioning, with an additional 26%

explained by its entry into the model, thereby increasing the overall variance accounted

for by the final model to 45%. However, none of the remaining patient characteristics

(i.e., age, gender, SES, time since diagnosis), psychosocial variables (i.e., social support),

or dimensions of acculturation (i.e., behavioral, familism, fatalism) significantly

contributed any additional variance to QLMI Social Functioning scores (see Table 4).

These findings suggest that patients with high medical severity and depressive symptoms

were associated with lower perceived social functioning than those Hispanic cardiac

patients with a lower severity of illness and fewer depressive symptoms.

Regression Models for Depression and Social Support

In addition to the three dimensions of cardiac patient adjustment, depression and

social support were predicted through a hierarchical multiple regression analysis (see









Table 4). Within each block entered, a stepwise selection procedure was utilized in

which predictor variables were entered in three separate steps. Step 1 entered five patient

characteristics (i.e., age, gender, SES, NYHA class, time since diagnosis) as a block

followed by social support (for depression) or depression (for social support) in the

second step, depending on the model tested, to examine the differential impact of each of

these variables on psychosocial functioning. The three indices of acculturation (i.e.,

behavioral, familism, fatalism) were then entered in the third step to examine the unique

contribution of behavioral acculturation, familism, and fatalism on depression and social

support, while controlling for patient characteristics and psychosocial variables.

Depression

As seen in Table 4, NYHA class and gender significantly accounted for 4% and

6% of the variance for scores on the CES-D, respectfully. Fatalism was also significant

and added an additional 7% of the variance to the model. Social support, as measured by

the MOS-SS, accounted for the greatest increment in variance for depression, with an

additional 17% explained by its entry into the model, thereby increasing the overall

variance accounted for by the final model to 34%. However, none of the remaining

patient characteristics (i.e., age, SES, time since diagnosis) or dimensions of acculturation

(i.e., behavioral, familism) significantly contributed any additional variance to CES-D

scores. These findings suggest that women, those with a higher degree of medical

severity, as well as those patients with low levels of social support and lack of perceived

control tend to endorse high levels of depressive symptomatology.









Social Support

Both gender of Hispanic cardiac patients and familism significantly predicted

scores on the MOS-SS, each accounting for 4% of the variance (see Table 4).

Depression, as measured by CES-D, was also significant and added an additional 18% of

the variance, increasing the overall variance accounted for by the final model to 26%.

None of the remaining patient characteristics (i.e., age, SES, time since diagnosis) or

dimensions of acculturation (i.e., behavioral, fatalism) significantly contributed any

additional variance to MOS-SS scores. These findings suggest that women, those with

nontraditional views of the family as a support system, and patients with a greater degree

of depressive symptoms were associated with lower levels of social support.
















DISCUSSION

The current study sought to investigate the psychosocial adjustment of Hispanic

cardiac patients to assist in identifying those patients at-risk for developing adjustment

difficulties as well as identifying factors associated with more favorable quality of life

outcomes.

Hispanic Patient Sample

The first objective was to examine the incidence of depression, degree of social

support and quality of life in a sample of Hispanic cardiac patients presenting to their

cardiologist. Results indicated that approximately 26% of the current sample endorsed

items reflective of depressive symptomatology. This was a somewhat high percentage

(based on CES-D scores alone and not confirmed by diagnostic interview) compared to

national prevalence data for Hispanic Americans, but within the 20 40% prevalence rate

of depression reported in prior studies of primarily Anglo-American cardiac samples

(Carney et al., 1995). This finding suggests that depressive symptoms could be

prominent in a sizable proportion of Hispanic cardiac patients and therefore, merits

further investigation as a potential risk factor for poor prognosis in this patient

population.

Second, about 86% of study participants described having a high degree of social

support available to them in terms of emotional and material support, receiving guidance,

and having positive social companionship. Finally, about 14% to 16% of the current









sample reported experiencing poor functioning in the areas of physical health, emotional

well-being, and social interactions. This finding is consistent with prior studies of

Hispanic medical patients (Jackson-Triche et al., 2000) and suggests that although a

proportion of patients may be experiencing adjustment difficulties, the majority are

adapting well with their cardiac illness and generally experience good quality of life.

Multidimensional Assessment of Hispanic Acculturation

A second purpose of the current study was to examine factors unique to Hispanic

culture, namely, acculturation, familism, and fatalism. Approximately 92% of Hispanic

cardiac patients in our sample were classified as being "low acculturated," suggesting

that the majority of participants are Spanish-speaking and therefore tend to use media

resources in Spanish and socialize with Hispanic peers. This finding is not surprising

given that the majority of study participants were characterized as Hispanic immigrants,

having resided in a predominantly Spanish-speaking community (i.e., south Florida) for

an average of 28 years, and self-identified as "Purely Hispanic." Therefore, in terms of

language use, this segment of the Hispanic population may not have had to struggle with

acculturative stress as much as perhaps other Hispanic Americans in different regions of

the United States, particularly as Hispanic immigrants to south Florida are guided to

available community resources upon arrival.

When examining the relationship between acculturation and specific Hispanic

cultural values, behavioral acculturation was related to familism but not fatalism. These

findings emphasize the enduring importance of the centrality of the family in this sample

of predominantly low acculturated cardiac patients, and the potential use of this Hispanic

cultural value as an emotional support system when coping with stressful life events.









Consistent with Keefe & Padilla's (1987) model of "selective acculturation", as the

acculturation process takes place, traditional Hispanic attitudes and behaviors related to

the family might diminish. This process may particularly occur for those Hispanic

patients that immigrated to the U.S. without members of their immediate or extended

family, thereby directing them towards seeking of alternative social networks. In

addition, the finding that fatalism was not significantly related to behavioral acculturation

may be due to several factors, including the size and level of heterogeneity within the

current patient sample. This finding highlights the need for future studies examining the

multidimensionality of the acculturation process and its measurement over time. As

expected, acculturation seemed to be facilitated in those participants who came from

higher socioeconomic backgrounds.

Cardiac-Related Quality of Life

Physical Functioning

The third objective of the study was to examine the role that psychosocial and

cultural dimensions may have in predicting cardiac-related quality of life (CQOL), while

controlling for specific demographic and medical factors. As predicted, Hispanic cardiac

patients that were depressed, had a higher degree of medical severity, and were female

appeared to experience lower levels of physical functioning, characterized by fatigue,

shortness of breath, chest pain, and limited sexual activity. Depression was found to be a

strong predictor of poor physical functioning, independent of cardiac disease severity

(NYHA class), demonstrating its potential role in exacerbating somatic symptoms and

disability, increasing health care utilization, and leading to higher morbidity and

mortality in this patient population (Friedman et al., 1995).









Social Functioning

Similarly, depressed patients and those with high levels of medical severity

seemed to participate in fewer social activities, feel excluded or burdensome to others,

and perceive having overprotective family members. This finding is consistent with prior

studies demonstrating the additive effects of both CHD diagnosis and depression on

reducing social functioning two-fold, compared to CHD or depression alone (Wells et al.,

1989). This result may be of particular importance in Hispanic cardiac patients who rely

on family support when dealing with stressful events. When depressed, these patients

may view supportive family members as being "overprotective" or feel that their medical

illness has placed a "burden" on the family, thereby contributing to a decreased number

of social interactions that are viewed as positive. As a result of deficits in social

functioning, these patients may also have a particularly difficult time dealing with their

cardiac illness on their own, leading to poor self-care behaviors, poor adherence to their

medical regimen, and subsequent medical complications (Katon & Sulllivan, 1990).

Emotional Functioning

Poor emotional well being characterized by feelings of frustration,

worthlessness, low self-esteem, and fear was found in those cardiac patients with low

levels of social support, high levels of medical severity, female gender, and fatalistic

perceptions. Consistent with prior studies of the stress-illness paradigm (Briones et al.,

1990; Oxman & Hull, 1997), the perceived availability of support networks in this patient

population appears to serve as a "buffer" to experiencing adverse emotional reactions

(e.g., anxiety, depression) in reaction to one's cardiac illness. However, female Hispanic

patients and those experiencing a number of health complications related to their heart









disease are patient subgroups that seem to be at heightened risk for developing adverse

emotional sequelae to their illness.

Interestingly, fatalism (i.e., Hispanic cultural value symbolizing lack of perceived

individual control) was found to be a significant predictor of poor emotional functioning,

even after controlling for other demographic, medical, and psychosocial factors.

Although fatalism has been interpreted as a potentially adaptive response to

uncontrollable life situations, particularly in U.S. minority groups (Neff & Hoppe, 1993),

results from the current study suggest that fatalistic attitudes may result in greater distress

in Hispanic cardiac patients as a result of passive coping responses with one's heart

disease and treatment plan, leading to adjustment difficulties and miscommunication

between the patient and his/her cardiologist.

Time Since Diagnosis

Contrary to a priori hypotheses, age, SES, time since diagnosis, acculturation, and

familism were not associated with any of the three dimensions of CQOL examined.

However, when CQOL was examined as a whole, patients living with heart disease for

two to four years demonstrated significantly better adjustment to their medical illness

than patients diagnosed for 10 or more years. Conceptually, this finding suggests that

recently diagnosed patients (< 2 years) may experience initial adjustment difficulties with

their heart disease due to a number of lifestyle changes that are associated with their

diagnosis. For example, this cohort of patients may experience limitations related to

physical exertion, various behavior changes (e.g., need to increase exercise, eat a

healthier diet, decrease smoking, and take medications), and role changes (i.e., increased

dependency on others) that interfere with their daily activities. After a period of time









(i.e., 2 to 4 years post-diagnosis), patients may learn how to adapt to these lifestyle

changes, leading to increased quality of life. However, the longer these patients live with

their heart disease, the more likely they are to encounter new adjustment issues as they

experience increased health complications with age, increased dependency on others, and

decreased social support, particularly in those patients who outlive members of their

support system.

Psychosocial Risk Factors

In addition to CQOL, factors associated with high levels of depression and social

support were examined given their importance as psychosocial risk factors and

prognostic indicators in those with heart disease. Depression tended to manifest itself in

those cardiac patients with low levels of social support, fatalistic views toward their

illness, high medical severity, and in women. In addition, women, those endorsing

depressive symptomatology, and those not viewing the family as a traditional support

system reported low availability of social support. These findings may be explained in

part by clinical observations of depressed individuals, particularly those who are living

with a chronic medical condition, who are often socially isolative or perceive having

negative interactions with others and therefore have less quality social support systems

available to them. Similarly, individuals with low social support are at increased risk for

developing psychological sequelae, such as depression, in response to lifestyle changes

related to their heart disease. Consequently, depressed cardiac patients may experience

feelings of hopelessness, loss of control, and low self-esteem.

The Hispanic cultural values of fatalism and familism also appeared to be

associated with depression and social support, respectively, via different coping









mechanisms. As previously mentioned, fatalism (lack of perceived control) may promote

depression and affect health outcomes through passive coping responses, often leading to

poor adjustment with one's medical condition and treatment plan. Conversely, the

Hispanic value of familism which perceives family as a source of identity, self-worth,

and social support may act as a protective buffer for many Hispanic cardiac patients

experiencing adjustment difficulties with their illness by facilitating the availability and

use of culturally congruent social networks, such as family and peers, to reinforce healthy

behaviors, provide healthy role models from one's own culture, and serve as a source of

emotional support.

Women and CHD

Consistent with prior studies of women with CHD, Hispanic women in the current

study reported higher levels of depression, lower levels of social support, and greater

adjustment difficulties with their heart disease than men, regardless of age or SES

(Nolen-Hoeksema, 1990; Shumaker & Czajkowski, 1993; Schron et al., 1991). An exact

reason for this difference is not known. These gender differences may be attributed to the

multiple role demands that women encounter, such as balancing work and interpersonal

commitments with their spouses, children, and friends. Balancing multiple roles, such as

work and interpersonal demands, has been shown to be an independent predictor for the

development and progression of CHD in women (Dixon, Dixon, & Spinner, 1991).

Hispanic women may be at equal or greater risk of experiencing psychological

and cardiac complications, in comparison to Hispanic men, particularly when they are

placed in the role of "the long suffering mother," also referred to as Marianismo in the

Hispanic culture. This cultural value refers to the spiritual superiority of the mother,









capable of enduring any suffering and self-sacrifice to help the husband and children, and

often attending to another family member's needs before her own (Bernal & Gutierrez,

1988). As a result of these family role expectations, these women may experience

increased social isolation as they cope with their cardiac illness alone, resulting in greater

distress, poorer functioning, and increased risk for depression. Women may be placed at

even greater risk for social isolation and its potentially adverse consequences as they

outlive their spouses, given their longer lifespan. These findings accentuate the need for

health care providers to give increased attention to women's role demands, cultural

values, role stressors, and level of social isolation and depression in interfering with the

treatment and quality of life of this cardiac patient population.

Limitations

The limitations in this study are primarily related to the demographic profile of

the Hispanic patient population sampled. Having conducted the study in a specialty

cardiology clinic in south Florida may have limited the participation of Hispanic cardiac

patients at different stages of the acculturation process. This concept is particularly

evident in that approximately 92% of Hispanic patients sampled were classified as "low

acculturated", predominantly Cuban-American (72%), and preferred to have the clinical

interview conducted in Spanish. Given the nature of the social environment in south

Florida and largely represented Hispanic community, it is feasible that many of the

Hispanic patients sampled did not have to experience the same acculturation issues that

other Hispanic communities in the U.S. may face. In particular, Hispanics residing in

south Florida have the resources available to maintain many cultural customs, such as

language use, media use, choice of social peers, food, and music. As a result, an









adequate sample of "high acculturated" or "bicultural" Hispanic patients was not

represented in the current study to demonstrate the level of heterogeneity that exists in the

Hispanic population on measures of psychosocial adjustment. This observation may also

account, in part, for behavioral acculturation (i.e., language use) not being a significant

predictor on specific dimensions of CQOL.

Similarly, a second limitation involved the Spanish-speaking ability of the

cardiologist from whom this sample of Hispanic cardiac patients sought treatment. There

is evidence suggesting that having a language-concordant physician is associated with

higher ratings of physical and emotional well-being by the patient, lower reported bodily

pain, increased compliance, and higher patient satisfaction (Perez-Stable, et al., 1997).

These findings may be related to a decrease in delay of health-seeking behavior on the

part of the patient and targeted treatment plans on the part of the physician, resulting from

direct communication in the patient-physician relationship. Communication in the

patient's native language decreases opportunities for misunderstandings regarding the

etiology, symptomatology, diagnosis, and treatment for presenting problems. Therefore,

the high percentage of Hispanic cardiac patients reporting moderate to high CQOL (84%

to 86%), may be related to having a physician with whom they could communicate with

in their native language. Consequently, the current sample may not be generalizable to

Hispanic cardiac patients who receive care from a language-discordant physician.

Of note, approximately 99% of our sample reported to have some form of health

insurance compared to 34% of the nation's 31 million Hispanic Americans having no

health insurance and 12% of Anglo Americans with no health insurance (Kilborn, 1999).

Nationally, while Hispanic Americans appear to be gaining in economic strength, they









disproportionately lack insurance coverage and ready access to health care. That is

particularly true for the three-quarters who are from Mexico and Central America.

Cuban-Americans (the predominant Hispanic subgroup sampled in the current study)

tend to be older, have a higher income, and are the most likely to have private health

insurance (74%) compared to Puerto Ricans, who most likely have Medicaid coverage

(32%), or Mexican Americans, who are the most likely to be uninsured (30%) (Council

on Scientific Affairs, 1991). Hispanic cardiac patients in the current study may also have

a higher rate of being insured due to their U.S. residency status (M = 28.1 years), which

easily surpasses the five-year wait requirement that legal Hispanic immigrants must meet

prior to applying for Medicaid. Cardiac patients, particularly those that experience some

form of health complication (e.g., heart attack), are also inherently more likely to be

eligible for disability payments in comparison to the general U.S. population (American

Heart Association, 1999). Given these discrepancies in health care coverage, the results

presented in the current study may not be as readily generalizable to Hispanic subgroups

that lack health insurance and access to health care services. Despite these limitations, a

number of compelling findings were obtained and require further investigation.

Future Directions

The present study provides greater insight into the psychosocial functioning of

Hispanic cardiac patients, a population in need of assessment given the scarce amount of

research conducted in this population. Research studies examining the cardiac-related

quality of life (CQOL) of Hispanic Americans are particularly important given the high

existing mortality rates from CHD and the increased prevalence of both traditional and

psychosocial risk factors in this patient population. Results from the current study are the









first to provide prevalence data of Hispanic patients who are coping well with their

cardiac illness versus those exhibiting adjustment difficulties. Second, psychosocial and

cultural factors were examined and found to have predictive value in identifying patient

subgroups at risk for experiencing poor CQOL. Consequently, results from the present

study provide a number of empirical and clinical implications for changing the focus of

current intervention modalities and public health policy.

In terms of Hispanic acculturation, the current investigation provides support for

examining acculturation as a multidimensional construct (encompassing one's behaviors,

attitudes, norms, and values) and demonstrates its potential to affect Hispanic cardiac

functioning through several mechanisms, including coping responses to illness (fatalism),

use of culturally congruent supportive networks in times of crisis familismm), and

effective communication through language concordant health care providers, media, or

social peers (behavioral acculturation). Utilizing this methodological approach implies

cultural growth along a continuum whereby an individual may adopt new values, while

simultaneously retain cultural values that may or may not contribute to poor CQOL. This

theoretical framework of cultural integration also accentuates the level of heterogeneity

present within the Hispanic community, reinforcing the importance of examining intra-

group differences in this population. Understanding the cultural context by which certain

adjustment and psychological disorders present themselves, particularly in chronic

illness, allows the healthcare provider to develop and utilize clinical tools that enhance

optimal patient care.

Second, results from the current study indicate that approximately 14 to 16% of

Hispanic patients experience adjustment difficulties related to their cardiac illness.









Within this group, patients exhibiting 1) high depressive symptoms, 2) low social

support, 3) high medical severity, and/or are 3) women are particularly "at-risk" for

developing complications in relation to their physical, emotional, and social functioning.

Moreover, Hispanic patients living with their cardiac diagnosis for 10 years or more are

more susceptible to poor CQOL compared to more recently diagnosed patients (2 to 4

years). Collectively, these findings identify subgroups of Hispanic cardiac patients that

are at high risk for experiencing poor CQOL and are in need of culturally-sensitive

interventions targeting reductions in depression and social isolation, while addressing the

special needs of this medical population.

Interventions targeting risk-reductions of cardiovascular lifestyle factors have

generally focused on secondary prevention efforts. In the realm of cardiac rehabilitation,

secondary prevention has been conceptualized as the development and implementation of

long-term strategies for patients who already have CHD, with the objective of decreasing

future cardiac events, improving quality of life, and prolonging life (Burell, 1996).

Targeted lifestyle factors may include behavioral (e.g., smoking, diet, sedentary activity)

and emotional (e.g., depression, social isolation) characteristics. Although medical and

surgical procedures have been developed to effectively ameliorate acute symptoms and

manifestations of CHD, lifestyle interventions have been recommended to produce long-

term impact on the course of the disease. Similarly, the mental health field has made

major advances in classifying mental disorders and developing treatments for many of

them. However, there has been almost no work conducted on preventing mental

disorders. Consequently, the development and evaluation of preventive intervention

efforts has been recommended by the Institute of Medicine, with special emphasis on









reducing the incidence of new cases of major depressive episodes (MDE) (Mufioz,

Mrazek, & Haggerty, 1996). Parallel to cardiac lifestyle interventions, focusing on the

prevention of depression has significant benefits not only for the patient but their

families, who also experience a great number of challenges as they attempt to confront

the issues surrounding cardiac disease.

Evidence from the present study strongly suggests that addressing and

ameliorating psychosocial risk factors in Hispanic cardiac patients necessitates culturally-

appropriate methods to assessment and access to services. For example, assessment

materials in the patient's preferred language should be made available to ensure accurate

reporting of symptoms and understanding of the adjustment issues that Hispanic cardiac

patients may encounter. Interestingly, study participants requested that the research

assessment battery be conducted via clinical interview versus self-report format. This

study observation is consistent with the Hispanic values ofpersonalismo and simpatia.

Personalismo refers to the dignified approach to personal associations that many

Hispanics prefer (Miranda et al., 1996). Important aspects of this personal approach

include the use of formal greetings when addressing patients in patient-provider

relationships, particularly as more traditional Hispanics have a tendency to value and

demonstrate a great deal of respect for their health care provider. Along with showing

respect, traditional Hispanics are expected to be warm and personal in their interactions

with others, a concept referred to as simpatia (Miranda et al., 1996). Likewise, Hispanics

tend to appreciate and respond well to the simpatia of others. Understanding these

cultural values become of vital importance in the recruitment of Hispanic patients for

clinical research, as traditional approaches to recruiting participants may be perceived as









both too informal or too cold. Therefore, having bilingual staff who treat older Hispanic

patients with respect, using formal titles, while being warm and personable, would

greatly enhance the successful recruitment and retaining of Hispanics into research

studies and improve accessibility to clinical services.

Results from the present study also suggest that routine screening practices for

depression, social isolation, and CQOL be made available for Hispanic patients that

present to their cardiologist. Once the screening results are received by the cardiologist,

clear directions should be made readily available as to what to do if the patient screens

positive. When screening is not routine, it should at least be available when requested by

either patient or the physician. Even in these settings, screening should be routine for

certain subsets of patients. Study findings suggest that subsets of Hispanic cardiac

patients particularly at risk for adjustment difficulties are those that 1) exhibit depressive

symptoms, 2) have low social support, 3) have several medical complications, and 4) are

female. Implementation of screening procedures would be highly important in Hispanic

cardiac patients given that this ethnic group has been found to receive comparatively less

mental health treatment than mainstream groups. Even though only 22% of Anglo

Americans who meet criteria for major depression receive mental health treatment, the

rate for Hispanics is even lower (11%) (Hough et al., 1987). This finding suggests that

Hispanics are either less likely to be identified by the health care system or to have access

to mental health services. Screening, using culturally valid measures, will help address

these barriers to accessing services and will also help cardiologists identify patients who

are experiencing poor CQOL for referral to clinical services.









Individuals who endorse high depressive symptoms should be provided with

alternative methods for increasing mood management skills and a rationale explaining

how negative mood states can reduce their ability to enjoy life, to express their love to

family and friends, and to manage their heart disease. Educational offerings (e.g., classes

to learn about mood and health) can be described in accurate and non-stigmatizing ways

as part of wellness interventions rather than exclusively for those who are at-risk. These

wellness interventions can be offered as part of cardiac rehabilitation programs to

improve lifestyle factors related to one's heart disease. Once patients are screened and

referred, they may then undergo a more careful assessment for medication evaluation

and/or prevention/treatment interventions. Having physicians who are willing to discuss

alternate treatments might increase patients' willingness to divulge their depression to

their doctor, discuss treatment they are receiving elsewhere, and allow their doctor to

collaborate with their treatment.

Hispanic Americans, who now number approximately 31 million and are quickly

becoming the largest minority group in the United States (Mein & Winkleby, 1998), are

showing substantial increases in depression and other cardiovascular disease risk factors

the longer they stay in the U.S., and their children show even higher rates (Sundquist &

Winkleby, 1999; Vega et al., 1998). Efforts to address these risk factors in Hispanic

Americans must begin with developing and evaluating culturally-sensitive prevention

intervention programs. This requires that

1) educational materials/pamphlets about both psychosocial and behavioral risk

factors for CHD be made available in Spanish and English for patients and their

family members;









2) Spanish-language versions of cardiac risk factor prevention interventions be

developed alongside English-language versions;

3) prevention interventions be offered as "courses" related to improving one's

lifestyle and adjustment to CHD, as well as reducing future CHD risk for one's

family, in order to reduce the stigma associated with mental health and normalize

the cardiac adjustment experience for patients;

4) interventions capitalize upon the value of Hispanic familism to decrease social

isolation, while utilizing a group format to share experiences of acculturation and

CHD in order to strengthen social connections within the Hispanic community;

5) interventions address fatalistic attitudes as a situational coping response with

alternative coping strategies being offered to deal specifically with one's CHD

(problem-focused coping); and

6) interventions address traditional Hispanic gender roles (e.g., marialismo) and their

impact on CQOL.

Future studies should examine the efficacy of these wellness interventions on

ameliorating clinical depression in this patient population in light of evidence

demonstrating that 42% of cardiac patients with subclinical depression subsequently

develop a MDE (Hance et al., 1996). In order to change health care policy, prevention

intervention programs must be able to demonstrate measurable improvements in mood

and behavioral risk factors. Preliminary studies have shown that cognitive-behavioral

mood management methods that focus on changing how we think, our activity levels,

and our interpersonal contacts can be used successfully to prevent the onset of clinical

depression in both English- and Spanish-speaking medical populations (Mufioz, 1997).









Further, there is evidence that the integration of psychosocial interventions within cardiac

rehabilitation programs leads to reduced cardiovascular morbidity and mortality in

comparison to those programs without this intervention component (Linden, 2000).

Collectively, these findings emphasize the need for the development, evaluation, and

future accessibility of cardiac risk factor prevention services for Hispanic cardiac

patients.

The policy implications and clinical impact of psychosocial factors in chronic

medical conditions are increasingly being assessed, not just by their prevalence and

associated mortality, but by their impact on patient adjustment and perceived well being

(Cassileth et al., 1984; Wells et al., 1989). The findings of the current study are

particularly important because of evidence that unaddressed psychological factors in

medical patients lead to poorer health outcomes and more expensive health care costs

(Friedman et al., 1995). Poor well being and functioning are also of policy interest

because of societal costs due to loss of productivity and use of health services (Wilson &

Drury, 1984). These factors may be especially evident in Hispanic populations where

cultural and social factors have been demonstrated to influence utilization of health care

services, appropriateness of health care sought, and compliance behaviors all of which

operate to determine one's functional status (Angel & Angel, 1997). The development

and integration of both psychological and behavioral CHD prevention programs within

health care settings allows for a more cost-efficient, comprehensive service approach for

patients.

Studies examining the cost-effectiveness of a prevention versus treatment

intervention model are particularly needed as the focus of healthcare has shifted.









Already, health care reform, especially the move toward managed care, demands that

health care services move from an emphasis on acute care, which is very costly, to early

preventive interventions, which, ideally, will reduce the need for acute care. It is up to

the health care providers of these patients to make sure that cultural and psychological

issues are part of this new focus.

In sum, the physical and psychological sequelae that survivors of CHD events

experience can be significant, requiring long periods of recovery and sometimes resulting

in long-term functional, social, and emotional deficits. A subset of Hispanic cardiac

patients may be particularly at risk for poor quality of life outcomes as the complex

process of acculturation leads to adopting and retaining values that may or may not aid

with cardiac adjustment. Results from the current study demonstrate the importance of

assessing psychosocial and cultural factors in Hispanic cardiac patients, particularly as

these variables were found to predict and differentiate at-risk groups on several

dimensions of quality of life. Members of the cardiology team can utilize this

information to enhance CQOL and reduce unnecessary suffering by developing and

evaluating culturally-appropriate interventions that improve access to services and

address the special needs of this population.
















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APPENDIX A
PATIENT INFORMATION INTERVIEW

Patient Information Interview
Department of Clinical & Health Psychology
University of Florida


INSTRUCTIONS: Please check ,all that apply:
1. Age: (years)


2. Sex: a Male


3. Which of the following best describes your current marital status? (select one item)
O Single/Never Married O Separated O Married
O Living together D Divorced O Widowed
4. Which of the following best describes your religious background? (select one item)
O Catholic Q Jewish Q Christian, with no formal religious affiliation
Q Protestant (denomination): __ Other:
5. What is the highest grade you completed in school? (select one item)
O 8th grade or less O Some high school 1 High school graduate/GED
Q Some college Q College graduate Q Post-graduate work
6. Which of the following best describes your current employment status? (select one item)
O Employed Full-Time Employed Part-Time Not employed
O Retired a Medically Disabled
7. Please state your most recent occupation:
8. Please state your average yearly income: ($ dollar amount)
9. What is your current insurance status? (select one item)


O Private Q Medicare


Q Medicaid


a HMO


I None


a Other


10. Please indicate which group best describes your ethnic or cultural background:


a White/Anglo
Q Cuban or Cuban American
O Mexican, Mexican-American, or Chicano/a
O Other Latino/Hispanic


11. What is your father's ethnic or cultural background?


12. What is your mother's ethnic or cultural background?
13. Where were you born?


. Puerto Rican
Q South American
0 Central American
. Mixed


(city/state/country)

(city/state/country)


14. Where was your father born?


15. Where was your mother born?


16. How many years have you lived in the United States?


(city/state/country)


(years)


17. Which of the following best describes you? (please circle one item)


3
Partly Latino/Hispanic
and Anglo-American


4
Somewhat
Anglo-American


5
Purely
Anglo-American


Q Female


(country)
(country)


Purely
Latino/Hispanic


Somewhat
Latino/Hispanic











HEALTHILIFESTYLE QUESTIONS

1. Has your doctor evertold you that you had any of the following conditions?
(Please choose either yes or no for each condition)

U Yes U No a. Congestive heart failure
U Yes U No b. Chronic lung disease (including bronchitis or emphysema)
U Yes U No c. Diabetes mellitus (high blood sugar)
U Yes U No d. Hypertension or high blood pressure
U Yes U No e. Angina or chest pain
U Yes U No f. Heart attack or myocardial infarction
U Yes U No g. Arrhythmia (abnormal heart rhythm)
U Yes U No h. Cancer

2. At what age did you first notice symptoms related to your current heart condition?


3. After you first noticed your heart symptoms, how much time passed before you went to the
doctor?
4. How many times have you been to the doctor in the past 6 months?
U Zero U 1 time U 2 times
U 3 times U 4 times U More than 4 times (number)
5. How often do you exercise?

U More than once a day U 4-7 times/week U 1-4 times/week
U Couple times/month U Once a month U Never
6. How vigorously do you exercise?

U Extremely vigorously U Somewhat vigorously
U Not very vigorously U NA

7. For how long have you been exercising?

U 10 or more years U 5-10 years U 2-5 years
U 1 year U Less than one year U NA

8. Have you ever or do you currently smoke?
U Yes, current smoker U Yes, past smoker U No

9. How many years did/have you smoke(d)?

10. On average, how much did (do) you smoke each day? Packs/day

11. Have you ever or do you currently drink alcoholic beverages (including beer, wine, hard
liquor/spirits)? UYes U No

12. How many years have/had you consumed alcohol?

13. On average, how often did (do) you consume alcohol?
U Daily (drinks/day) U 2-3 times/weekly U Weekly
U 2-3 times/month U Once a month U Almost Never










APPENDIX B
CES-D MEASURE

CES-D Measure

Below is a list of the ways you might have felt or behaved. For each question, please
indicate how often you have felt this way during the past week.

Rarely or None of Some or a Little of Occasionally or a Most or All of
the Time the Time Moderate Amount the Time (5-7
DURING THE PAST WEEK: (Less than 1 Day) (1-2 Days) of Time (3-4 Days) Days)

1. I was bothered by things that don't usually bother me... O O O O

2. I did not feel like eating; my appetite was poor............ O O O O

3. I felt that I could not shake off the blues even with help
from my family or friends................ ................... O

4. 1 felt I was just as good as other people................ O O O O

5. 1 had trouble keeping my mind on what I was doing...... O O O O

6. 1 felt depressed .................. .......................... ]O O O]

7. 1 felt that everything I did was an effort................. O O O O

8. 1 felt hopeful about the future................ .............. O O O

9. 1 thought my life had been a failure......................... O O O

10. I felt fearful ................................................... O O O O]

11. My sleep was restless ................ ...... O O O

12. I was happy ........... ..... ............... .......... ... ]O O O

13. I talked less than usual ......................... O O O

14. I felt lonely.................. . ....... . ....... .

15. People were unfriendly .................. ........ O O O

16. 1 enjoyed life............................................. O O O O]

17. I had crying spells ............... ..... .................. ] O

18. I felt sad ........... ......... .. ............... O O

19. 1 felt that people disliked me ............... ...... O O O

20. I could not "get going"................... .... ... .. O O O O




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