FLORIDA HEART STUDY: PSYCHOSOCIAL ADJUSTMENT OF
HISPANIC HEART PATIENTS
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
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
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
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
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
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
Guido G. Urizar Jr.
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).
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 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.
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
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 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
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 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
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
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
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 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 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
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
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).
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
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.
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
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.
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%).
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.
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.
Demographic characteristics of study participants
Characteristic n % Characteristic n % Characteristic n %
75 and above
8th grade or less
Some high school
HS graduate / GED
Partly Hispanic &
CAD & Cardiomyopathy
CAD & CHF
CAD, Cardiomyopathy, CHF
Years Since Diagnosis
1 year or less
2 4 years
5 9 years
10 or more years
30% or less
Cardiovascular risk factor profile of study participants
Factor n %0 Factor n % IFactor n % Factor n %
> 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
Extremely Vigorous 4 3.3
Somewhat Vigorous 23 19.2
Not Very Vigorous 35 29.2
Not Applicable 58 48.3
Current Smoker 13 10.8
Past Smoker 64 53.4
None 43 35.8
14 11.8 Yes
105 88.2 No
Male > 45
Female > 55
LDL > 130
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.
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
and Standard Deviations of Study Variables
13 14 M
7 -.12 65.9
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
= 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.
1 year or less 2-4 years 5-9 years 10 or more
Time Since Diagnosis
lime Since Diagnosis
Figure 1. Mean Scores of Global Quality of Life by Time Since Cardiac Diagnosis
NYHA Class I NYHA Class II NYHA Class III
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.
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
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
Figure 3. Models for the Three Planned Regression Analyses
Time Since Diagnosis
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
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
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.
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.
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.
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
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
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
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).
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).
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
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
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.
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.
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
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
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
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.
Aaronson, N.K. (1988). Quality of life: What is it? How should it be measured?
Oncology, 2, 69-74.
Adler, N., & Matthews, K. (1994). Health psychology: Why do some people get
sick and some stay healthy? Annual Review of Psychology, 45, 229-259.
Ailinger, R.L. (1989). Functional capacity of Hispanic elderly immigrants.
Journal of Applied Gerontology, 8(1), 97-109.
Ailinger, R.L., Dear, M.R., & Holley-Wilcox, P. (1993). Predictors of function
among older Hispanic immigrants: A five-year follow-up. Nursing Research, 42(4), 240-
American Heart Association (1999). Coronary heart disease. In Coronary heart
disease and angina pectoris [On-line]. Available:
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
Angel, J.L., & Angel, R.J. (1992). Age at migration, social connections, and
well-being among elderly Hispanics. Journal of Aging and Health, 4(4), 480-499.
Angel, R. J., & Angel. J. L. (1997). Health service use and long-term care among
Hispanics. In K. S. Markides & M. R. Miranda (Eds.), Minorities, aging, and health (pp.
343-366). Thousand Oaks, CA: Sage.
Angel R., & Guamaccia, P.J. (1989). Mind, body, and culture: Somatization
among Hispanics. Social Sciences Medicine, 28, 1229-1238.
Aranda, M.P., & Knight, B.G. (1997). The influence of ethnicity and culture on
the caregiver stress and coping process: A sociocultural review and analysis. The
Gerontologist, 37(3), 342-354.
Atkins, C., Patterson, T., Roppe, B., Sallis, J., & Nader, P. (1987). Health habits
and the decision to volunteer for a family health promotion project. American Journal of
Preventive Medicine, 3, 87-94.
Bardis, P.D. (1959). A familism scale. Marriage and Family Living, 21, 340-
Barefoot, J.C. (1997). Depression and coronary heart disease. Cardiologia, 42,
Barefoot, J.C., Larsen, S., von der Leith, L., & Schroll, M. (1995). Hostility,
incidence of acute myocardial infarction, and mortality in a sample of older Danish men
and women. American Journal of Epidemiology, 142, 477-484.
Barefoot, J.C., & Schroll, M. (1996). Symptoms of depression, acute myocardial
infarction, and total mortality in a community sample. Circulation, 93, 1976-1980.
Becker, T.M., Wiggins, C., Key, C.R., & Samet, J.M. (1988). Ischemic heart
disease mortality in Hispanics, American Indians, and non-Hispanic whites in New
Mexico, 1958-1982. Circulation, 78, 302-309.
Berkman, L.F. (1995). The role of social relations in health promotion.
Psychosomatic Medicine, 57, 245-254.
Berkman, L.F., & Syme, L. (1979). Social networks, host resistance and
mortality: A nine-year follow-up study of Alameda County residents. American Journal
of Epidemiology, 109(2), 186-204.
Berkman, L.F., Vaccarino, V., & Seeman, T. (1993). Gender differences in
cardiovascular morbidity and mortality: The contribution of social networks and
support. Annals of Behavioral Medicine, 15(2-3), 112-118.
Bemal, G. & Gutierrez, M. (1988). Cubans. In L. Comas-Diaz & E.H.G. Erna
(Eds.), Clinical guidelines in cross-cultural mental health. Wiley series in general and
clinical psychiatry (pp. 233-261). New York: Wiley.
Berry, J.W. (1998). Acculturative stress. In P.B. Organista & K.M. Chun (Eds.),
Readings in ethnic psychology (pp. 117-122). Florence, KY: Taylor and Francis.
Blazer, D.G. (1982). Social support and mortality in an elderly community
population. American Journal of Epidemiology, 115, 684-694.
Blumenthal, J.A., Jiang, W., Babyak, M.A., Krantz, D.S., Frid, D.J., Coleman,
R.E., Waugh, R., Hanson, M., Appelbaum, M., O'Conner, C., & Morris, J.J. (1997).
Stress management and exercise training in cardiac patients with myocardial ischemia.
Archives of Internal Medicine. 157. 2213-2223.
Briones, D.F., Heller, P.L., Chalfant, H.P., Roberts, A.E., Aguirre-Hauchbaum,
S.F., & Farr, W.F. (1990). Socioeconomic status, ethnicity, psychological distress, and
readiness to utilize a mental health facility. American Journal of Psychiatry, 147(10),
Brummett, B.H., Babyak, M.A., Barefoot, J.C., Bosworth, H.B., Clapp-Channing,
N.E., Siegler, I.C., Williams, R.B., Mark, D.B. (1998). Social support and hostility as
predictors of depressive symptoms in cardiac patients one month after hospitalization: A
prospective study. Psychosomatic Medicine, 60, 707-713.
Burchfiel, C.M., Hamman, R.F., Marshall, J., Baxter, J., Kahn, L.B., & Amirani,
J. (1990). Cardiovascular risk factors and impaired glucose tolerance: The San Luis
Valley study. American Journal of Sociology, 131(1), 57-70.
Burell, G. (1996). Group psychotherapy in Project New Life: Treatment of
coronary-prone behaviors for patients who have had coronary artery bypass graft surgery.
In R. Allan & S. Scheidt (Eds.), Heart and mind (pp. 291-312). Washington, DC:
American Psychological Association
Burnam, M., Hough, R., Karno, M., Escobar, J., & Telles, C. (1987).
Acculturation and lifetime prevalence of psychiatric disorders among Mexican
Americans in Los Angeles. Journal of Health and Social Behavior, 28, 89-102.
Caralis, P.V. (1990). Hypertension in the Hispanic-American population.
American Journal of Medicine, 88(Suppl 3B), 9-16.
Carney, R.M., Freedland, K.E., Rich, M.W., & Jaffe, A.S. (1995). Depression as
a risk factor for cardiac events in established coronary heart disease: A review of possible
mechanisms. Annals of Behavioral Medicine, 17, 142-149.
Carroll, D., Davey Smith, G., & Bennett, P. (1996). Some observations on health
and socioeconomic status. Journal of Health Psychology, 1, 23-36.
Case, R.B., Moss, A.J., & Case, N. (1992). Living alone after myocardial
infarction. Journal of the American Medical Association, 267, 515-519.
Cassileth, B.R., Lusk, E.J., & Strouse, T.B. (1984). Psychosocial status in chronic
illness: A comparative analysis of six diagnostic groups. New England Journal of
Medicine, 311, 506-511.
Cervantes, R. & Castro, F. (1985). Stress, coping and Mexican American mental
health: A systematic review. Hispanic Journal of Behavioral Sciences, 7, 1-73.
Chamberlain, K. (1997). Socioeconomic health differentials: From structure to
experience. Journal of Health Psychology, 2, 399-411.
Chandler, C. (1979). Traditionalism in a modem setting: A comparison of Anglo
and Mexican-American value orientations. Human Organization, 38, 153-159.
Chwalow, A.J. (1995). Cross-cultural validation of existing quality of life scales.
Patient Education and Counseling, 26, 313-318.
Cohen, R. (1979). Culture, disease and stress among Latino immigrants.
Washington, DC: Smithsonian Institution.
Cohen, S. (1988). Psychosocial models of the role of social support in the
etiology of physical disease. Health Psychology, 12, 269-297.
Corin, E. (1994). The social and cultural matrix of health and disease. In R.G.
Evans, M.L. Barer, & T.R. Marmor (Eds.), Why are some people healthy and others not?
The determinant of health of populations (pp. 93-133). New York: Aldine de Gruyter.
Cortes, D.E. (1995). Variations in familism in two generations of Puerto Ricans.
Hispanic Journal of Behavioral Sciences, 17(2), 249-255.
Council on Scientific Affairs. (1991). Hispanic health in the United States.
Journal of the American Medical Association, 265(2), 248-252.
Cuellar, I., Arnold, B., & Maldonado, R. (1995). Acculturation rating scale for
Mexican Americans-II: A revision of the original ARSMA scale. Hispanic Journal of
Behavioral Sciences, 17(3), 275-304.
Cuellar, I., Harris, L.C., & Jasso, R. (1980). An acculturation scale for Mexican
American normal and clinical populations. Hispanic Journal of Behavioral Sciences, 2,
Dempster, M., & Donnelly, M. (2000). Measuring the health related quality of
life of people with ischaemic heart disease. Heart, 83, 641-644.
Derenowski, J. (1990). Coronary artery disease in Hispanics. Journal of
Cardiovascular Nursing, 4(4), 13-21.
Dixon, J.P., Dixon, J.K., & Spinner, J.C. (1991). Tensions between career and
interpersonal commitments as a risk factor for cardiovascular disease among women.
Women and Health, 17, 33-57.
Federal register. (1978, May 4). Washington, DC: Government Printing Office.
Forster, L.E., & Stoller, E.P. (1992). The impact of social support on mortality: A
seven-year follow-up of older men and women. Journal of Applied Gerontology, 1,
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). Depression following
myocardial infarction: Impact on 6-month survival. Journal of the American Medical
Association, 270, 1819-1825.
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). Depression and 18-
month prognosis after myocardial infarction. Circulation, 91, 999-1005.
Frerichs, R.R., Aneshensel, C.S., & Clark, V.A. (1981). Prevalence of depression
in Los Angeles county. American Journal of Epidemiology, 113, 691-699.
Friedman, H.S., Tucker, J.S., & Reise, S.P. (1995). Personality dimensions and
measures potentially relevant in health: A focus on hostility. Annals of Behavioral
Medicine, 17, 245-253.
Friedman, R., Sobel, D., Myers, P., Caudill, M., & Benson, H. Behavioral
medicine, clinical health psychology, and cost offset. Health Psychology, 14(6), 509-
Garza, R.T., & Gallegos, F.I. (1985). Environmental influences and personal
choice: A humanistic perspective on acculturation. Hispanic Journal of Behavioral
Sciences, 7, 365-379.
George, L., & Fillenbaum, G. (1985). The OARS methodology: A decade of
experience in geriatric assessment. Journal of the American Geriatric Society, 33, 607-
Ginn, J. & Arber, S. (1991). Class and income inequalities in later life. British
Journal of Sociology, 42(3), 369-396.
Goff, D.C., Ramsey, D.J., Labarthe, D.R., & Nichaman, M.Z. (1993). Acute
myocardial infarction and coronary heart disease mortality among Mexican Americans
and non-Hispanic whites in Texas, 1980 through 1989. Ethnicity and Disease, 3, 64-
Greenfield, S., Sullivan, L., Dukes, K.A., Silliman, R., D'Agostino, R., & Kaplan,
S.H. (1995). Development and testing of a new measure of case mix for use in office
practice. Medical Care, 33(4), AS47-AS55.
Griffith, J., & Villavicencio, S. (1985). Relationships among acculturation,
sociodemographic characteristics and social support in Mexican American adults.
Hispanic Journal of Behavioral Sciences, 7, 75-92.
Guarnaccia, P.J., Angel, R., & Worobey, J.L. (1989). The factor structure of the
CES-D in the Hispanic health and nutrition examination survey: The influences of
ethnicity, gender, and language. Social Science and Medicine, 29(1) 85-94.
Guyatt, G.H., Veldhuyzen Van Zanten, S.J., Feeny, D.H., & Patrick, D.L. (1989).
Measuring quality of life in clinical trials: A taxonomy and review. Canadian Medical
Association Journal, 140, 1441-1448.
Hance, M., Carney, R.M., Freedland, K.E., & Skala, J. (1996). Depression in
patients with coronary heart disease: A 12-month follow-up. General Hospital
Psychiatry, 18, 61-65.
Hanson, B.S., Isacsson, S.O., Janzon, L., & Lindell, S.E. (1990). Social network
and social support influence mortality in elderly men. Advances, 7, 16-18.
Haynes, S.G., Harvey, C., Montes, H., Nickens, H., & Cohen, B.H. (1990).
Patterns of cigarette smoking among Hispanics in the United States: Results from the
HHANES 1982-1984. American Journal of Public Health, 80, 47-53.
Hazuda, H.P., Haffner, S.M., Stern, M.P., & Eifler, C.W. (1988). Effects of
acculturation and socioeconomic status on obesity and glucose intolerance in Mexican-
American men and women. American Journal of Epidemiology, 120, 494.
Hillers, T.K., Guyatt, G.H., Oldridge, N., Crowe, J., Willan, A., Griffith, L., &
Feeny, D. (1994). Quality of life after myocardial infarction. Journal of Clinical
Epidemiology, 47(11), 1287-1296.
Hill, D.R., Kelleher, K. & Shumaker, S.A. (1992). Psychosocial interventions in
adult patients with coronary heart disease and cancer: A literature review. General
Hospital Psychiatry, 14S, 28S-42S.
Hollingshead, A.B. (1975). Four factor index of social status. New Haven, CT:
Holohan, C.J., & Holohan, C.K., Moos, R.H. (1995). Social support, coping, and
depressive symptoms in a late-middle-aged sample of patients reporting cardiac
illness. Health Psychology, 14, 152-163.
Holohan, C.J., Holohan, C.K., Moos, R.H. (1997). Social context, coping
strategies, and depressive symptoms: An expanded model with cardiac patients. Journal
of Personality and Social Psychology, 72, 918-928.
Hough, R.L., Landsverk, J.A., Karno, M., Burnam, A., Timbers, D.M., Escobar,
J.I., & Regier, D.A. (1987). Utilization of health and mental health services by Los
Angeles Mexican Americans and non-Hispanic whites. Archives of General Psychiatry,
House, J.S., Umberson, D., & Landis, K. (1988). Structures and processes of
social support. Annual Review of Sociology, 14, 293.
Hurst, J.W., Morris, D.C., & Alexander, R.W. (1999). The use of the New York
Heart Association's classification of cardiovascular disease as part of the patient's
complete problem list. Clinical Cardiology, 22, 385-390.
Jackson-Triche, M.E., Sullivan, J.G., Wells, K.B., Rogers, W., Camp, P., &
Mazel, R. (2000). Depression and health-related quality of life in ethnic minorities
seeking care in general medical settings. Journal of Affective Disorders, 58(2), 89-97.
Juarbe, T.C. (1996). The state of Hispanic health: Cardiovascular disease and
health. In S. Torres (Ed.), Hispanic voices: Hispanic health educators speak out (pp. 93-
113). New York, NY: National League for Nursing.
Kaplan, G.A. (1995). Where do shared pathways lead? Some reflections on a
research agenda. Psychosomatic Medicine, 57, 208-212.
Katon, W., Kleinman, A., & Rosen G. (1994). Depression and somatization: A
review. American Journal of Medicine, 72, 127-135.
Katon, W., & Sullivan, M.D. (1990). Depression and chronic medical illness.
Journal of Clinical Psychiatry, 51(6S), 3-11.
Keefe, S.E., & Padilla, A.M. (1987). Chicano ethnicity. Albuquerque: University
of New Mexico Press.
Keefe, S.E., Padilla, A.M., & Carlos M.L. (1979). The Mexican-American
extended family as an emotional support system. Human Organization, 38, 144-152.
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman,
S., Wittchen, H.U., & Kendler, K.S. (1994). Lifetime and 12-month prevalence ofDSM-
III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-
Kilborn, P.T. (1999). Third of Hispanic Americans do without health coverage
[On-line]. Available: http://www.nytimes.com/yr/mo/day/news/national/hispanics-
Kinney, M.R., Burfitt, S.N., Stullenbarger, E., Rees, B., & Debolt M.R. (1996).
Quality of life in cardiac patient research: A meta-analysis. Nursing Research, 45(3),
Krause, N., & Tran, T. (1989). Stress and religious involvement among older
Blacks. Journal of Gerontoloev: Social Sciences. 44. S4-13.
Krumholz, H.M., Butler, J., Miller, J., Vaccarino, V., Williams, C.S., Mendes de
Leon, C.F., Seeman, T.E., Kasl, S.V., & Berkman, L.F. (1998). Prognostic importance of
emotional support for elderly patients hospitalized with heart failure. Circulation, 97(10),
Kubzansky, L.D., Weiss, S.T., & Sparrow, D. (1998). Anxiety and coronary heart
disease: A synthesis of epidemiological, psychological, and experimental evidence.
Annals of Behavioral Medicine, 20(2), 47-58.
LaFromboise, T., Coleman, H.L.K., & Gerton, J. (1993). Psychological impact of
biculturalism: Evidence and theory. Psychological Bulletin, 114(3), 395-412.
Liao, Y., Cooper, R.S., Cao, G., Kaufman, J.S., Long, A.E., & McGee, D.L.
(1997). Mortality from coronary heart disease and cardiovascular disease among adult
U.S. Hispanics: Findings from the national health interview survey (1986 to 1994).
Journal of the American College of Cardiology, 30(5), 1200-1205.
Linden, W. (2000). Psychological treatments in cardiac rehabilitation: Review of
rationales and outcomes. Journal of Psychosomatic Research, 48(4-5):443-454.
Littman, A.B. (1993). Review of psychosomatic aspects of cardiovascular
disease. Psychotherapy & Psychosomatics, 60, 148-167.
Manson, A. (1988). Language concordance as a determinant of patient
compliance and emergency room use in patients with asthma. Medical Care, 26, 1119.
Marcus, A., & Crane, L. (1985). Smoking behavior among U.S. Latinos: An
emerging challenge for public health. American Journal of Public Health, 75(2), 169-
Marin, G. (1992). Issues in the measurement of acculturation among Hispanics.
In K.F. Geisinger (Ed.), Psychological testing of Hispanics (pp. 235-252). Washington,
DC: American Psychological Association.
Marin, G. (1993). Influence of acculturation on familism and self-identification
among Hispanics. In M.E. Bemal & G.F. Knight (Eds.), Ethnic identity: Formation
among Hispanics and other minorities (pp. 181-196). New York: State University
of New York Press.
Marin, G., & Marin, B.V. (1991). Issues in identifying Hispanics. In L. Bickman
& D.J. Rog (Eds.), Research with Hispanic populations: Applied social research methods
series, Volume 23 (pp. 18-41). Newbury Park, CA: Sage Publications, Inc.
Marin, G., Marin, B.V., Perez-Stable, E.J., Otero-Sabogal, R., & Sabogal, F.
(1990). Cultural differences in attitudes and expectancies between Latino and non-Latino
White smokers. Hispanic Journal of Behavioral Sciences, 12, 422.
Marin, G., Otero-Sabogal, R., Perez-Stable, E.J., Sabogal, F., & VanOss-Marin,
B. (1987). Development of a short acculturation scale for Hispanics. Hispanic
Journal of Behavioral Sciences, 9(2), 183-205.
Markides, K.S., & Lee, D.J. (1991). Predictors of health status in middle-aged
and older Mexican Americans. Journal of Gerontology, 46(5), S243-249.
Marks, G., Garcia, M., & Solis, J.M. (1990). Health risk behaviors of Hispanics
in the United States: Findings from HANES, 1982-84. American Journal of Public
Health, 80, 20-26.
Marmot, M.G., & Smith, D.G. (1997). Socioeconomic differentials in health: The
contribution of the Whitehall studies. Journal of Health Psychology, 2, 283-296.
Marmot, M.G., Smith, D.G., & Stansfeld, D. (1991). Health inequalities among
British civil servants: The Whitewall II study. Lancet, 337, 1387-1392.
Marmot, M., & Winkelstein, W. (1975). Epidemiologic observations on
intervention trials for prevention of coronary heart disease. American Journal of
Epidemiology, 101(3), 177-181.
McCarthy, J., & Yancey, W. (1971). Uncle Tom and Mr. Charlie: Metaphysical
pathos in the study of racism and personal disorganization. American Journal of
Sociology, 76, 648-672.
Medalie, J., & Goldbourt, V. (1976). Angina pectoris among 10,000 men: II.
Psychosocial and other risk factors as evidenced by a multivariate analyses of a five year
incidence study. American Journal of Medicine, 60, 910-921.
Mein, S., & Winkleby, M.A. (1998). Concerns and misconceptions about
cardiovascular disease risk factors: A focus group evaluation with low-income Hispanic
women. Hispanic Journal of Behavioral Sciences, 20(2), 192-211.
Miranda, J., Azocar, F., Organista, K.C., Mufioz, R.F., & Lieberman, A. (1996).
Recruiting and retaining low-income Latinos in psychotherapy research. Journal of
Consulting and Clinical Psychology, 64(5), 868-874.
Mirowsky, J., & Ross, C.E. (1984). Mexican culture and its emotional
contraindications. Journal of Health and Social Behavior, 25, 2-13.
Mitchell, B.D., & Stern, M.P., Haffner, S.M., Hazuda, H.P., Patterson, J.K.
(1990). Risk factors for cardiovascular mortality in Mexican-Americans and non-
Hispanic Whites: The San Antonio Heart Study. American Journal of Epidemiology,
Moreno, C., Alvarado, M., Balcazar, H., Lane, C., Newman, E., Ortiz, G., &
Forrest, M. (1997). Heart disease education and prevention program targeting immigrant
Latinos: Using focus group responses to develop effective interventions. Journal of
Community Health, 22(6), 435-50.
Moscicki, E.K., Locke, B.Z., Rae, D.S., & Boyd, J.H. (1989). Depressive
symptoms among Mexican Americans: The Hispanic Health and Nutrition Examination
Survey. American Journal of Epidemiology, 130, 348-360.
Moscicki, E.K., Rae, D.S., Regier, D.A., & Locke, B.Z. (1987). The Hispanic
Health and Nutrition Examination Survey: Depression among Mexican Americans,
Cuban Americans, and Puerto Ricans. In M. Gaviria & J.D. Arana (Eds.), Health and
behavior: Research agenda for Hispanics (pp. 145-159). Chicago: University of
Muller, J.E., Abela, G.S., & Nesto, R.W. (1994). Triggers, acute risk factors and
vulnerable plaques: The lexicon of a new frontier. Journal of the American College of
Cardiology, 23, 809.
Mufioz, R.F. (1997). The San Francisco Depression Prevention Research Project.
In G.W. Albee & T.P. Gullota (Eds.), Primary prevention works (pp. 380-400).
Thousand Oaks, CA: Sage Publications.
Mufioz, R.F., Mrazek, P.J., & Haggerty, R.J. (1996). Institute of medicine report
on prevention of mental disorders. American Psychologist, 51(11), 1116-1122.
Nanjundappa, G., & Friis, R. (1985). Diabetes, depression and Hispanic and non-
Hispanic ethnicity. Migration Today, 13, 39-44.
National Center for Health Statistics. (1996). Advance report of final mortality
statistics, 1993. Monthly Vital Statistics Report, S44(7), 65.
Neff, J.A., & Hoppe, S.K. (1993). Race/ethnicity, acculturation, and
psychological distress: Fatalism and religiosity as cultural resources. Journal of
Community Psychology, 21, 3-20.
Negy, C., & Woods, D.J. (1992). The importance of acculturation in
understanding research with Hispanic Americans. Hispanic Journal of Behavioral
Sciences, 4(2), 224-247.
Nolen-Hoeksema, S. (1990). Sex differences in depression. Stanford, CA:
Stanford University Press.
Oldridge, N., Guyatt, G., Jones, N., Crowe, J., Singer, J., & Feeny, D. (1991).
Effects on quality of life with comprehensive rehabilitation after acute myocardial
infarction. American Journal of Cardiology, 67, 1084-1089.
Olmedo, E. (1979). Acculturation: A psychometric perspective. American
Psychologist, 34(11), 1061-1070.
Orth-Gomer, K., Rosengren, A., & Wilhelmsen, L. (1993). Lack of social support
and incidence of coronary heart disease in middle-aged Swedish men. Psychosomatic
Medicine, 55, 37-43.
Orth-Gomer, K., Unden, A.L., & Edwards, M.E. (1988). Social isolation and
mortality in ischemic heart disease. New England Journal of Medicine, 311, 552-559.
Oxman, T.E., Freeman, D.H., & Manheimer, E.D. (1994). Social support and
depression after cardiac surgery in elderly patients. American Journal of Geriatric
Psychiatry, 2, 309-323.
Oxman, T.E., & Hull, J.G. (1997). Social support, depression, and activities of
daily living in older heart surgery patients. Journal of Gerontology, 52B, 1-14.
Padilla, A.M. (1995). Hispanic psychology: Critical issues in theory and research.
Thousand Oaks, CA: Sage.
Pearlin, L.I., & Schooler, C. (1978). The structure of coping. Journal of Health
and Social Behavior, 19, 2-21.
Perez-Stable, E. (1987). Issues in Latino health care. The Western Journal of
Medicine, 146(2), 213-218.
Perez-Stable, E.J., Marin, G., Marin, B.V. (1994). Behavioral risk factors: A
comparison of Latinos and non-Latino whites in San Francisco. American Journal of
Public Health, 84, 971.
Perez-Stable, E.J., Napoles-Springer, A., & Miramontes, J.M. (1997). The effects
of ethnicity and language on medical outcomes of patients with hypertension or diabetes.
Medical Care, 35(12), 1212-1219.
Perez-Stable, E.J., Sabogal, F., Otero-Sabogal, R., Hiatt, R.A., & McPhee, S.J.
(1992). Misconceptions about cancer among Latinos and Anglos. Journal of the
American Medical Association, 268, 3219.
Portillo, C.J., White, M.C., Baisden, K., & Dawson, C. (1995). Angina,
functional impairment and physical inactivity among Mexican-American women with
depressive symptoms. Progress in Cardiovascular Nursing, 10(3), 18-25.
Quadagno, D., Nation, A.J., Johnson, D., Waitley, C., Waitley, N., Epstein, D., &
Satterwhite, A. (1995). Cardiovascular disease and sexual functioning. Applied Nursing
Research, 8(3), 143-146.
Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for
research in the general population. Applied Psychological Measurement, 1, 385-401.
Radloff, L.S., & Locke, B.Z. (1986). The community mental health assessment
survey and the CES-D scale. In M.M. Weissman, J.D. Myers, & C.E. Ross (Eds.),
Community surveys of psychiatric disorders (pp. 177-189). New Brunswick, NJ:
Rutgers University Press.
Roberts, R.E. (1981). Prevalence of depressive symptoms among Mexican
Americans. Journal of Nervous Mental Disorders, 169, 213-219.
Rodriguez, E.R. (1996). The sociocultural context of stress and depression in
Hispanics. In S. Torres (Ed.), Hispanic voices: Hispanic health educators speak out (pp.
143-158). New York, NY: National League for Nursing.
Rodriguez, J.M., & Kosloski, K. (1998). The impact of acculturation on
attitudinal familism in a community of Puerto Rican Americans. Hispanic Journal of
Behavioral Sciences, 20(3), 375-390.
Ruberman, W., Weinblatt, E., & Goldberg, J.D. (1984). Psychosocial influences
on mortality after myocardial infarction. New England Journal of Medicine, 311, 552-
Sabogal, F., Marin, G., Otero-Sabogal, R., VanOss Marin, B., & Perez, E.J.
(1987). Hispanic familism and acculturation: What changes and what doesn't? Hispanic
Journal of Behavioral Sciences, 9(4), 397-412.
Sabogal, F., Otero-Sabogal, R., Perez-Stable, E.J., VanOss-Marin, B., & Marin,
G. (1989). Perceived self-efficacy to avoid cigarette smoking and addiction: Differences
between Hispanics and non-Hispanic Whites. Hispanic Journal of Behavioral Sciences,
Salgado de Snyder, V.N., & Padilla, A.M. (1987). Social support networks: Their
availability and effectiveness. In M. Gaviria & J.D. Arana (Eds.), Health and behavior:
Research agenda for Hispanics (pp. 93-107). Chicago: University of Illinois Press.
Schron, E.B., Pawitan, Y., Shumaker, S.A., & Hale, C. (1991). Health quality of
life differences between men and women in a postinfarction study. Circulation, 84
(Suppl. II), 245.
Schumaker, S.A., & Czajkowski, S.M. (1993). A review of health-related quality
of life and psychosocial factors in women with cardiovascular disease. Annals of
Behavioral Medicine, 15, 149-161.
Seijo, R., Gomez, H., & Freidenberg, J. (1991). Language as a communication
barrier in medical care for Latino patients. Hispanic Journal of Behavioral Sciences, 13,
Shapiro, P.A. (1996). Psychiatric aspects of cardiovascular disease.
Consultation-Liaison Psychiatry, 19(3), 613-629.
Shea, S., Stein, A.D., Basch, C.E., Lantigua, R., Maylahn, C., Strogatz, D.S., &
Novick, L. (1991). Independent associations of educational attainment and ethnicity with
behavioral risk factors for cardiovascular disease. American Journal of Epidemiology,
Sherbourne, C.D., & Stewart, A.L. (1991). The MOS social support survey.
Social Science and Medicine, 32(6), 705-714.
Shetterly, S.M., Baxter, J., Mason, L.D., & Hamman, R.F. (1996). Self-rated
health among Hispanic vs. non-Hispanic White adults: The San Luis Valley Health and
Aging Study. American Journal of Public Health, 86(12), 1798-1801.
Siddharthan, K., & Sowers-Hoag, K. (1989). Elders' attitudes and access to
health care: A comparison of Cuban immigrants and native-born Americans. The Journal
of Applied Gerontology, 8, 86-96.
Sorlie, P.D., Backlund, E., Johnson, N.J., & Rogot, E. (1993). Mortality by
Hispanic status in the United States. JOURNAL of the American Medical Association,
Stern, M., Gaskill, S., Allen, C., Garza, V., Gonzalez, J., & Waldrop, R. (1981).
Cardiovascular disease risk factors in Mexican-Americans in Laredo, Texas: Prevalence
of overweight diabetes and distribution of serum lipids. American Journal of
Epidemiology, 113, 546-555.
Stern, M., Rosenthal, M., Haffner, S., Hazuda, H., & Franco, L. (1984). Sex
differences in the effects of sociocultural status on diabetes and cardiovascular risk
factors in Mexican-Americans: The San Antonio Heart Study. The American Journal of
Epidemiology, 120, 834-851.
Sundquist, J. & Winkleby, M.A. (1999). Cardiovascular risk factors in Mexican
American adults: A transcultural analysis ofNHANES III, 1988-1994. American Journal
of Public Health, 89(5),723-730.
Szapocznick, J., Scopetta, M.A., Kurtines, W., & Aranalde, M.A. (1978). Theory
and measurement of acculturation. Interamerican Journal of Psychology, 12, 113-130.
Todd, K.H., Samaroo, N., Hoffman, J.R. (1993). Ethnicity as a risk factor for
inadequate emergency department analgesia. Journal of the American Medical
Association, 269, 1537.
Tran, T.V., Fitzpatrick, T., Berg, W.R., & Wright, R. (1996). Acculturation,
health, stress, and psychological distress among elderly Hispanics. Journal of Cross-
Cultural Gerontology, 11, 149-165.
Trevino, F.M., Moyer, M.E., Valdez, R.B., & Stroup-Benham, C.A. (1991).
Health insurance coverage and utilization of health services by Mexican Americans,
mainland Puerto Ricans, and Cuban Americans. Journal of the American Medical
Association, 265, 233-237.
Triandis, H.C., Marin, G., Betancourt, H., Lisansky, J., & Chang, B. (1982).
Dimensions of familism among Hispanics and mainstream Navy recruits. Chicago:
University of Illinois, Department of Psychology.
Umberson, D. (1987). Family status and health behaviors: Social control as a
dimension of social integration. Journal of Health and Social Behavior, 28, 306-319.
U.S. Bureau of the Census. (1993). The Hispanic population in the United States:
March 1992 (Current Population Reports, Series P20, No. 465RV). Washington, DC:
U.S. Government Printing Office.
Valenti, L., Lim, L., Heller, R.F., & Knapp, J. (1996). An improved questionnaire
for assessing quality of life after acute myocardial infarction. Quality of Life Research,
Valle, R., & Martinez, C. (1980). Natural networks among Mexicano elderly in
the United States: Implications for mental health. In M.R. Miranda & R.A. Ruiz (Eds.),
Chicago aging and mental health. Washington, DC: U.S. Government Printing Office.
Vega, W.A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E., Catalano, R., &
Caraveo-Anduaga, J. (1998). Lifetime prevalence of DSM-III-R psychiatric disorders
among urban and rural Mexican Americans in California. Archives of General
Psychiatry, 55, 771-778.
Vega, W., Sallis, J., Patterson, T., Rupp, J., Atkins, C., & Nader, P. (1987).
Assessing knowledge of cardiovascular health-related diet and exercise behaviors in
Anglo and Mexican-Americans. Preview of Medicine, 16, 696-709.
Vega, W., Warheit, G., & Meinhard, K. (1984). Marital disruption and the
prevalence of depressive symptomatology among Anglos and Mexican Americans.
Journal of Marriage and The Family, 46, 817-824.
Weissman, M.M., Sholomskas, D., & Pottenger, M. (1977). Assessing depressive
symptoms in five psychiatric populations: A validation study. American Journal of
Epidemiology, 106, 203-214.
Wells, K.B., Stewart, A., Hays, R.D., Burnam, A., Rogers, W., Daniels, M.,
Berry, S., Greenfield, S., & Ware, J. (1989). The functioning and well-being of
depressed patients: Results from the Medical Outcomes Study. Journal of the American
Medical Assocation, 262(7), 914-919.
Wild, S.H., Laws, A., Fortmann, S.P., Varady, A.N., & Byrne, C.D. (1995).
Mortality from coronary heart disease and stroke for six ethnic groups in California, 1985
to 1990. Annals of Epidemiology, 5, 432-439.
Williams, R.B., Barefoot, J.C., Califf, R.M. (1992). Prognostic importance of
social and economic resources among medically treated patients with angiographically
documented coronary artery disease. Journal of the American Medical Association, 267,
Williams, R.B., & Littman, A.B. (1996). Psychosocial factors. In M.H.
Crawford, J. Abrams, & R.C. Pasternak (eds.), Cardiology clinics, Vol. 14 (pp. 97-104).
Philadelphia, PA: W.B. Saunders.
Williams, R.B., Barefoot, J.C., & Blumenthal, J.A. (1997). Psychosocial
correlates of job strain in a sample of working women. Archives of General Psychiatry,
Wilson, R.W., & Drury, T.F. (1984). Interpreting trends in illness and disability:
Health statistics and health status. Annual Review of Public Health, 15, 83-106.
Yates, B.C. (1995). The relationships among social support and short-and long-
term recovery outcomes in men with coronary heart disease. Research and Nursing
Health, 18, 193-203.
Zich, J. M., Attkisson, C. C., & Greenfield, T. K. (1990). Screening for
depression in primary care clinics: the CES-D and the BDI. International Journal of
Psychiatry in Medicine, 20(3), 259-77.
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
10. Please indicate which group best describes your ethnic or cultural background:
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
14. Where was your father born?
15. Where was your mother born?
16. How many years have you lived in the United States?
17. Which of the following best describes you? (please circle one item)
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
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
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