The effects of acculturation on viewpoints of successful aging among community-dwelling older adults of Mexican Origin

The present study tested whether views about aging successfully in bicultural individuals as described in the literature, physical functioning, or social engagement and support depend on the individual's level of acculturation. Sixty-seven community-dwelling adults from California and New Mexico, who identified either as Mexican or Mexican American, between the ages of 55 to 88 participated in the study. The data were collected in English or Spanish, using self-report questionnaires that measured acculturation (Short Acculturation Scale for Hispanics), physical functioning (SF-12), and social support (Lubben Social Network Scale). A survey developed by Phelan and colleagues to assess attributes described in the successful aging literature was used to capture the participants' thoughts about aging successfully. Multiple regression analyses controlling for age revealed that acculturation was not significantly related to perceptions of aging, physical health, or social support. The results of the present study highlight the need for successful aging research with culturally diverse samples and the benefits of studying differences within the Latino population. As the Latino population is the largest ethnic minority in the 65 and older category in the United States, culturally sensitive approaches that promote successful aging behaviors among older adults of Mexican origin are necessary to support the demands of an increasingly older minority population.

THE EFFECTS OF ACCULTURATION ON VIEWPOINTS OF SUCCESSFUL AGING AMONG COMMUNITY-DWELLING OLDER ADULTS OF MEXICAN ORIGIN by Daisy Elizabeth Gosset-Swann A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Educational Psychology The University of Utah August 2018 Copyright © Daisy Elizabeth Gosset-Swann 2018 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Daisy Elizabeth Gosset-Swann has been approved by the following supervisory committee members: John C. Kircher , Chair 04/18/2018 Date Approved Janiece L. Pompa , Member 04/18/2018 Date Approved Lora Tuesday-Heathfield , Member 04/18/2018 Date Approved Amy Jo Metz , Member 04/18/2018 Date Approved Scott D. Wright , Member 04/18/2018 Date Approved and by the Department/College/School of Anne Cook , Chair/Dean of Educational Psychology and by David B. Kieda, Dean of The Graduate School. ABSTRACT The present study tested whether views about aging successfully in bicultural individuals as described in the literature, physical functioning, or social engagement and support depend on the individual’s level of acculturation. Sixty-seven communitydwelling adults from California and New Mexico, who identified either as Mexican or Mexican American, between the ages of 55 to 88 participated in the study. The data were collected in English or Spanish, using self-report questionnaires that measured acculturation (Short Acculturation Scale for Hispanics), physical functioning (SF-12), and social support (Lubben Social Network Scale). A survey developed by Phelan and colleagues to assess attributes described in the successful aging literature was used to capture the participants’ thoughts about aging successfully. Multiple regression analyses controlling for age revealed that acculturation was not significantly related to perceptions of aging, physical health, or social support. The results of the present study highlight the need for successful aging research with culturally diverse samples and the benefits of studying differences within the Latino population. As the Latino population is the largest ethnic minority in the 65 and older category in the United States, culturally sensitive approaches that promote successful aging behaviors among older adults of Mexican origin are necessary to support the demands of an increasingly older minority population. To my son, Cashel: I hope to leave a better world for you. To my parents and mother-in-law: The inspiration behind my research. TABLE OF CONTENTS ABSTRACT…………………………………………………………………………….. iii LIST OF TABLES………………………………………………………………..…… vii ACKNOWLEDGMENTS………………………………………………………...…… viii Chapters 1. INTRODUCTION ……………………………………………………………………. 1 1.1 Successful Aging ……………………………………………………………. 3 1.2 The Aging Minority …………………………………………………………. 5 1.3 Acculturation ………………………………………………………………... 7 1.4 Physical Functioning and Disease ………………………………………… .. 9 1.5 Engagement with Life ……………………………………………………… 12 1.5.1 Active Engagement ………………………………………………. 13 1.5.2 Occupational Engagement ……………………………........…...... 14 1.5.3 Social Engagement/Social Network ……………………………... 14 1.5.4 Social Support ……………………………………………………. 15 1.6 Current Study ………………………………………………………………. 16 2. METHODOLOGY ………………………………………………………………….. 19 2.1 Participants …………………………………………………………………. 19 2.2 Measures ………………………………………………………………….... 19 2.2.1 Acculturation ……………………………………………………... 19 2.2.2 Successful Aging ………………………………………………… 20 2.2.3 Subjective Health ………………………………………………… 21 2.2.4 Social Support ……………………………………………………. 22 2.2.5 Demographics ……………………………………………………. 23 2.3 Procedures ………………………………………………………………….. 24 3. RESULTS …………………………………………………………………………… 28 3.1 Descriptive Analysis ……………………………………………………….. 28 3.2 Preliminary Analysis ……………………………………………………….. 29 3.3 Evaluation of Statistical Assumptions …………………………………...… 30 3.4 Primary Analysis …………………………………………………………… 30 3.5 Exploratory Analysis ...….…………………………………………………. 32 3.6 Summary …………………………………………………………………… 33 4. DISCUSSION ……………………………………………………………………….. 39 4.1 Summary …………………………………………………………………... 39 4.2 Findings ……………………………………………………………………. 41 4.2.1 Research Question 1 …………………………………………...… 41 4.2.2 Research Question 2 ………………………………………….….. 43 4.2.3 Research Question 3 ………………………………….……..…… 44 4.3 Limitations …………………………………………………………………. 45 4.4 Implications ………………………………………………………………… 47 4.5 Future Research ………………………………………..…..………………. 48 Appendices A. ENGLISH MEASURES …………………………………………………………… 51 B. SPANISH MEASURES ……………………………………………………………. 67 REFERENCES ………………………………………………………………………… 81 LIST OF TABLES Tables 2.1 Summary of Data Analysis and Collection Process ……..………………………… 27 3.1 Children and Grandchildren ………………………………………………………... 34 3.2 Marriage and Living Situation …………………………………………………..…. 34 3.3 Number of Years Living in the United States …………………………………….... 34 3.4 Education …………………………………………………………………..…….… 35 3.5 Instruments: Means, Standard Deviations, Observed Ranges, and Coefficient Alphas………………………………………………………………………………...… 35 3.6 Correlation Matrix …………………………………………………………...…….. 35 3.7 Skewness and Kurtosis Statistics …………………………..………………………. 36 3.8 Model Summary for Hypothesis 1 …………...…………………………….…….… 36 3.9 Model Summary for Hypothesis 2 …………...…………………………….…….… 36 3.10 Model Summary for Hypothesis 3 …………...……………………………...….… 37 3.11 “Your Ideas About Growing Older” Subscales …………………………..…….… 38 ACKNOWLEDGMENTS I want to thank my husband, Jonathan, for the tremendous encouragement and unconditional love you have provided throughout my studies and dissertation work. I want to express gratitude to my mother, Daisy: Gracias, mamá, por todo tu amor, apoyo, y confianza en mi capacidad para tener éxito en mis estudios. I also owe a great deal of appreciation to my father, Manny, for offering me the means to pursue my passion and inspiring my work. To my aunt/mother, Manuela: Mil gracias por ser una influencia positive en mi vida y por tantos años de educación que me has dado. To my sister, Marilyn: You are my biggest supporter. You have influenced my life in more ways than I can ever tell you. To my brother, Omar, and sister-in-law, Yesenia: Your determination in life has been a great example for me to follow. I would like to acknowledge Cashel, Layla, and Berlyn: One day, you three will set out to conquer the world, making it better, different, and more accepting. For my friends, Kalani, Beatriz, and Jessica: Thank you for your relentless encouragement, intellectual stimulation, and enjoyable times especially during the difficult periods of this trajectory. Finally, I would not have been able to complete this significant requirement for my doctoral degree without the positive reassurance from my mentor, Sue Morrow, the continuous guidance and support from my chair, John Kircher, and the invaluable time from my committee members. Thank each and every one of you for continuing to motivate me along this very extensive journey. CHAPTER 1 INTRODUCTION The percentage of the United States population aged 65 and older has increased significantly in the last two decades and is predicted to triple in the next thirty years (McLaughlin, Connell, Heeringa, Li, & Roberts, 2010; West, Cole, Goodkind, & He, 2014). This wave or “swell” of adults transitioning into older adulthood is often referred to as the “Silver Tsunami” (Bartels & Naslund, 2013; Potkanowicz, Hartman-Stein, & Biermann, 2009; Summer, 2007). Between now and 2030, approximately 10,000 adults in the United States will turn 65 years old each day (Centers for Disease Control, 2013). This shift in the population has resulted in greater societal importance of issues that are relevant to the older adult population. In recent years, a large body of empirical research has attempted to characterize the aging process, using socio-contextual labels that focus on the physical and/or emotional features of growing old. Among these labels, “successful aging” has been prominent, especially in relation to the role of health and behavioral lifestyle factors that impact the aging process. In other words, advice regarding successful aging, which currently dominates the research literature and is pervasive in the popular media, has focused on what people can do to stave off or postpone the aging process, including engaging in exercise, getting regular medical checkups, eating a healthy diet, and staying engaged with one’s family and community. 2 More succinctly, Rowe and Kahn (1997) describe the model of successful aging as having a “low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement with life” (p.443). Rowe and Kahn’s model has drawn significant attention and debate because these factors have been linked to objective measures of adjustment and well-being in later life. To be sure, many of these, including individualistic striving for the maintenance of physical fitness and optimal health through accessing the public health system, are ideals that have a universal appeal. It is clear, however, that the concept of successful aging has favored a Eurocentric viewpoint promoting self-centered aspects of well-being (e.g., “maintaining my own sense of health and happiness is essential to adjustment in old age”). The labeling of the aging process in this way gives rise to questions about whether the aging process is also affected by cultural factors and whether the model of successful aging is applicable to other cultures. I will begin this first chapter by providing an overview of the theoretical perspective of successful aging as conceptualized by John Rowe and Robert Kahn. It will be followed by an estimation of the size of the older adult population in the United States that is classified as being of Hispanic origin. I will then explain the importance of acculturation in examining issues pertaining to older adults of Hispanic or Latino origin. Next, two specific concepts of successful aging will be highlighted: physical functioning and engagement with life. Definitions, disparities, and trends in each of these concepts will be reviewed. I will conclude with describing how this dissertation is designed to address gaps in our knowledge of successful aging as it applies to older adults of Mexican origin. (Note that the terms “Latino” and “Hispanic” are used interchangeably 3 throughout this dissertation.) 1.1 Successful Aging In 1987, Rowe and Kahn stated that in order for people to understand the experience of aging, the older adult population should not be dichotomized as “diseased” or “nondiseased,” pointing out that particular attention be given to the heterogeneity that exists among older adults. This prompted the recommendation for researchers to differentiate between older adults experiencing average age-related declines from those experiencing better than average aging (Rowe & Kahn, 1987). A decade later, Rowe and Kahn developed criteria to classify older adults as having experienced successful aging (Rowe & Kahn, 1997). The criteria included (a) having low probability of illness, meaning to be free from disease and physical disability; (b) having high cognitive and physical functioning capacity; and (c) being actively engaged with life, including being productive and engaging in interpersonal activities (Rowe & Kahn, 1997). Despite the acceptance and popularity of the term “successful aging,” there was no consensus on a standard for defining and measuring features associated with this model (Pruchno, Wilson-Genderson, & Cartwright, 2010). For example, Baltes and Baltes (1990), along with other researchers, looked at successful aging from a psychosocial framework, while other researchers, such as Fries (1990) and Rowe and Kahn (1987), contributed to this model from a more clinical standpoint. Young, Frick, and Phelan (2009) and Valliant and Mukamal (2001) considered this model from both perspectives in efforts to develop a more cohesive definition. Yet other researchers expanded the criteria for successful aging by looking at cross-cultural aspects of aging 4 (Hsu, 2007; McLaughlin et al., 2010; Phelan, Anderson, LaCroix, & Larson, 2004). Potential elements for the framework of successful aging have been investigated with older adults in numerous studies with the expectation of finding a definition that could be operationalized and applied to a general older adult population. While Rowe and Kahn’s model has been widely accepted, it is important to acknowledge a few of the criticisms and limitations of their theory. One criticism is that elements of this theory stem from a value system that may or may not be universal across other older adults (McLaughlin et al., 2010; Phelan et al., 2004; Strawbridge, Wallhagen, & Cohen, 2002). For example, Phelan and colleagues noted in their 2004 study that Rowe and Kahn’s model identifies several key factors (i.e., remaining active, staying healthy, and maintaining social relationships) that respondents in their study agreed were important. However, participants did not seem to value other elements as important, such as volunteering after retirement. Researchers further criticized this model as relying on Western values and ideals, suggesting that the integration of other cultural perspectives would give this model a more holistic approach by reflecting the values of a more diverse population (McLaughlin et al., 2010; Wada, Mortenson, & Hurd Clarke, 2016). Another major criticism of Rowe and Kahn’s model is the lack of emphasis on the roles of social and environmental factors. Some researchers agree that this model stresses personal agency and responsibility for lifestyle, and does not consider the structural elements of health that contribute to health disparities experienced by some groups (Dillaway & Byrnes, 2009). For example, some studies have noted that individuals from a lower socioeconomic status are likely to experience higher rates of obesity, smoking, and alcohol abuse (Ferraro, 2006; Vaillant & Mukamal, 2001; Zolnikov, 2015), which 5 can directly impact any of the three components of Rowe and Kahn’s model. Despite various limitations cited in the literature since the early beginnings of this concept, research on successful aging has evolved from a biomedical model to a multidimensional construct. Successful aging is now seen as an objective and subjective process of continuous adaptation and adjustment to aging that is unique to each person (Tam, 2014). Since the term successful aging was first introduced in the literature, researchers have attempted to define, quantify, and generalize various elements of this model. As Bowling (1993) pointed out, definitions of successful aging will always be culturally biased, because they are defined by an individual’s cultural values. However, researchers from all over the world have found that some elements of this model seem to be endorsed by older adults worldwide (see Amin, 2017; Cha, Seo, & Sok, 2014; Cosco et al., 2015; Feng, Son, & Zeng, 2015; Fernandez-Ballesteros et al., 2010; Lewis, 2014; Nguyen & Seal, 2014; Parslow, Lewis, & Nay, 2011; Zanjari, Sani, Chavoshi, Rafiey, & Shahboulaghi, 2016). It is important to reiterate that the successful aging theory should continue to evolve in order to construct a concept that can be cross-culturally relevant and match the needs of a growing, more diverse older adult population. 1.2 The Aging Minority As previously stated, the older adult population in the United States has seen the largest increase in history and is expected to rise. Foreseeably, racial and ethnic diversity also will increase among the older adult population in the United States. According to the 2010 U.S. Census Bureau, the total older adult population is 40.2 million, 20% of which is represented by all people who self-identify as Hispanic Whites. Older adults of 6 Hispanic or Latino origin are increasing in number and represent the fastest growing minority group, representing 7% or 2.9 million of the population 65 and older. Accordingly, current reports indicate that the largest racial and ethnic minority in the 65 and older group is the Hispanic population, which by 2050 is estimated to double in size, growing to 17.5 million (U.S. Census Bureau, 2014). In addition, Latinos of Mexican origin represent the largest segment of the elderly Latino population (U.S. Census Bureau, 2010). The demographic shifts in the population of older adults in the United States has resulted in an increased interest in research on ethnic differences on issues relevant to older adults, in particular the health care needs of this segment of the increasingly older and more ethnically diverse American population (Neary & Mahoney, 2005). A few studies have examined whether, in Latino older persons, the absence or avoidance of disease (Goodwin, Black, & Satish, 1999), and the strong emphasis on maintaining cognitive function (Samper-Ternent et al., 2008), both germane to successful aging ideology, are associated with markers of well-being. Other studies have focused on specific aspects of the successful aging paradigm in terms of the role of active engagement and helping others in life (Miko & Sanchez, 2001) and its relationship to well-being. A limited few have examined the relationship of cultural factors to successful aging among older Latinos (Angel, 2009; McLaughlin et al., 2010). For example, McLaughlin et al. explored the relationship between race and successful aging, making it one of the few studies to include race as a possible moderator of successful aging. Their criticism of the successful aging model falls in line with others who have questioned the 7 relevancy of this model as it applies to more diverse populations. 1.3 Acculturation While for decades the roles of race and culture were ignored in the successful aging ideology, it is likely that these roles play a part in shaping the experience of aging. In particular, acculturation has been largely overlooked in studies about aging. If race and culture shape identities and form attitudes, it seems reasonable that acculturation also could affect perceptions of aging successfully. Therefore, the importance of investigating this hypothesis to establish public health strategies that can effectively promote both physical and psychological well-being in ethnic minority groups, or whether this ideology is even viewed as relevant to well-being in Latinos, is essential. Acculturation refers to the process by which members of a minority ethnic group incorporate both their heritage culture and the mainstream culture into their self-identity to accommodate information about, and experiences within, the mainstream culture (Ryder, Alden, & Paulhus, 2000). Acculturation is affected and can be measured by many factors including (but not exclusive to) language, the age immigration occurred, and number of years living in a country (Satia-Abouta, Patterson, Neuhouser, & Elder, 2002). The influence of acculturation has been cited repeatedly in the cross-cultural literature as having relevance in both the physiological and psychological functioning of individuals from ethnically diverse populations (Black, Markides, & Miller, 1998; Chiriboga, Black, Aranda, & Markides, 2002; Garcia et al., 2015; Vinuesa, 2004). Research examining acculturation among Latinos and a host of variables such as depression, self-esteem, and health also is extensive in the literature. However, the 8 population most noticeably absent in studies of acculturation is older adults. Only a handful of studies examine the effects of acculturation on older adults of Hispanic or Latino origin (Chavez-Korell, Benson-Florez, Rendón, & Farías, 2014; Espino & Maldonado, 1990; Garcia et al. 2015; Krause & Goldenhar, 1992; Markides & Black, 1996) and even fewer incorporate the successful aging model. Chiriboga, Jang, Banks, and Kim (2007) examined acculturation and its effect on depression on an older adult population. The results of their study suggest that Latino older adults of Mexican American origin experience differing symptoms of depression based on their level of acculturation. Another problem to note is that even within the ethnic composition of those labeled as ‘Hispanic’ or ‘Latino,’ there is much variability. Aside from a common Spanish language, these individuals may immigrate from different countries, have diverse cultural backgrounds and practices, and be at different levels of acculturation (Jolicoeur & Madden, 2002; Miyawaki, 2014). This is where acculturation emerges as a promising paradigm for studying within-group variability. It could be argued that in a predominantly Spanish-speaking community, views other than those found within the contemporary paradigm of successful aging could contribute to the experience of growing old. Meyler, Stimpson, and Peek (2005) investigated the relationship between language acculturation and self-esteem among Mexican American adults aged 65 and older. They found that individuals having more language acculturation had higher levels of self-esteem even when experiencing depressive symptomology. Conversely, lower levels of acculturation in Latinos have been found to contribute to more disability in functions relating to daily life (Garcia et al., 2015). Garcia et al. (2015) examined the 9 effects of nativity and acculturation on life expectancy among elders of Mexican origin. They found that older adults born in Mexico that are living in the United States live longer than older adults of Mexican origin born in the United States. However, older adults born in Mexico experience more physical limitations. The study further revealed that women who were less acculturated experienced greater physical limitations when compared to men (Garcia et al., 2015). 1.4 Physical Functioning and Disease Rowe and Kahn (1998) posited that everyone has the capacity to age successfully, and that aging successfully is determined by the health behaviors that individuals engage in. Rowe and Kahn often measured successful aging in terms of the health of an individual. However, they did not suggest that natural age-related decline was preventable, but rather that functional deterioration could be reduced (Versey, Stewart, & Duncan, 2013). We know today that physical disability among the elderly is a major public health problem that requires substantial health care expenditures and greatly affects their quality of life (Ferrucci et al., 1996; Martin, Freedman, Schoeni, & Andreski, 2009). McLaughlin et al. (2010) reported that based on Rowe and Kahn’s definition of successful aging, only 11.9% of older adults in the United States aged successfully. Limitations in physical functioning (i.e., problems in walking, using stairs, and performing basic household tasks) directly affect the older adults’ ability to perform other tasks of daily living necessary for self-care and independent living (Sachs-Ericsson, Schatschneiderm, & Blazer, 2006). Although an important public health goal is to increase life expectancy, of greater importance is that extended life should include the 10 capacity to live independently and to function well (Katz, 1983). Physical inactivity is a leading factor for chronic disease (King et al., 2000), which has been increasing among older adults (Martin et al., 2009). The loss of activities of daily living that depend upon mobility also represent a serious decline in elders’ functional health (Hand, Cavanaugh, Forbes, Govern, & Cress, 2012), overall cognitive functioning (Prohaska & Peters 2007), and engagement in social activities (Berlin & Klenosky, 2014). Participating regularly in exercise and other forms of physical activity has been attributed to slowing down the aging process and most importantly, minimizing functional decline (Hand et al., 2012; King et al., 2000). Older adults who remain physically active tend to report higher life satisfaction and improved cognitive functioning, two components directly related to the successful aging ideology (Dogra & Stathokostas, 2012; Prohaska & Peters, 2007; Taran, Sabiston, & Taivassalo, 2014). Prohaska and Peters (2007) found that high cognitive functioning results in better management of an individual’s Alzheimer’s disease and other forms of dementia. They further report that the positive effects of physical activity on cognitive functioning have been found at each level of prevention. In terms of cultural variables affecting physical functioning, collectively, Latinos living in the United States suffer from poorer health outcomes when compared to nonHispanic Whites (Rogers, 2010). Williams, Neighbors, and Jackson (2003) report that socioeconomic factors, lifestyle behaviors, social environment, and access to preventive health-care services are among the factors contributing to racial or ethnic health disparities among Hispanics and their non-Hispanic White counterparts. Several studies have indicated that Latinos have a higher incidence of depression, obesity, and diabetes 11 (Aranda, Lee, & Wilson, 2001; Chavez-Korell et al., 2014). Minority cultures, specifically those of Latino origin, are at a disadvantage not solely based on economic hardship or the strains associated with language barriers in gaining access to health care (Angel, 2009; Rogers, 2010), but with regard to the impact of their cultural beliefs regarding health-related behaviors. The way people perceive health and illness and how these perceptions interact with cultural context clearly impact the ways in which people utilize health care (Rogers, 2010). Acculturation as part of an individual’s culture influences the way people think about health. However, there is mixed research inferring the extent to which acculturation contributes to health behaviors. Research from Buscemi, Williams, Tappen, and Blais (2012) found that individuals who are more acculturated report better mental health status but not better physical health. In contrast, González, Tarraf, and Haan (2011) report that higher acculturation is associated with a lowered metabolic syndrome risk (waist circumference, blood pressure, glucose, and triglycerides) in older Mexican American adults born in Mexico. One topic that is abundant in the literature is that acculturation is a stressful process of adjustment (Smart & Smart, 1995; Ward, Bochner, & Furnham, 2001) and that acculturative stress, the impact of adapting to a new culture, particularly affects health (Caplan, 2007). However, most of the research on acculturative stress refers specifically to adolescents and/or young adults. Again, the need for acculturative stress research on an older adult population of Latino or Hispanic origin cannot be overstated. In general, stress is a factor that can negatively affect health by causing physical changes in the body and altering physiological processes (Vogel & Romano, 1999). It also can increase the 12 likelihood of maladaptive behaviors and lifestyle choices that can adversely affect health and worsen a variety of medical conditions (Broderick, 2000; Green, Baker, Smith, & Sato, 2003). Reducing stress can prove challenging among low-income and minority populations who continue to face a myriad of stressors beyond their control (Farley, Galvez, Dickinson, & Diaz-Perez, 2005). Several researchers have suggested rather than reducing stress among the Hispanic population, a better strategy might be to devise healthier and more effective coping mechanisms that can minimize the harmful effects of stress (Farley et al., 2005). For example, emphasizing social support is a coping style that consistently has been associated with better health (Blake & Vandiver, 1988; Sherbourne, Hays, & Wells, 1995). 1.5 Engagement with Life Another component of the tripartite theory of successful aging, as defined by Rowe and Kahn, emphasizes the importance of remaining actively engaged with life. They state, “Successful aging goes beyond potential; it involves activity” (p.433). One major aspect of successful aging involves interacting with others through active and regular participation in activities; in other words, staying involved and engaged (Rowe & Kahn, 1997). Elements of engagement with life have been examined from various approaches in the literature of successful aging. For example, gardening to improve dietary habits (Robson & Troutman-Jordan, 2015), singing (Teater & Baldwin, 2014) and ballroom dancing (Stevens-Ratchford, 2016) to promote self-development, and volunteering as a means to remain socially connected (Chen, 2016). The fundamental idea is to promote independence and maximize functioning that should, in turn, reduce 13 the risk of disability, disease, and dysfunction. Remaining active, engaged, and maintaining a healthy and positive outlook on life is key to aging successfully Most recently, Cosco et al. (2015) found four primary engagement themes in their cross-cultural study: active engagement (physically or socially), occupational engagement (volunteering or working past retirement), social engagement (interpersonal relationships and/or maintaining a strong social network), and social support. These four themes seem to capture the overarching premise of engagement with life as discussed within the paradigm of successful aging. This dissertation will focus on the latter two: social engagement and social support. 1.5.1 Active Engagement Active engagement with life consists of two areas: participation in activities that are productive and positive, and maintaining social relationships (Sabbath et al., 2015; Rowe & Kahn, 1998). Activities mentioned in the study by Cosco et al. (2015) were engaging in hobbies, participating in exercise groups, and meeting friends. Participants in their study also reported staying involved with family activities, such as helping raise grandchildren, as a way to remain actively engaged with life (Cosco, 2015). Han and Patterson (2004) support the idea that participating in activities that are leisurely serve as a framework for experiencing positive emotions. Taking this idea one step further, Ong, Bergeman, Bisconti, and Wallace (2006) found evidence to support the hypothesis that positive emotions may be beneficial to managing stressful situations. In a study of Mexican Americans over the age of 65, Ostir, Ottenbacher, and Markides (2004) recognized that the risk of participants to become frail over time was significantly 14 reduced when high positive affect was present. Consequently, it appears that individuals who experience more positive emotions are more likely to participate and engage in activities that are both productive and positive, consistent with the concept of aging successfully. 1.5.2 Occupational Engagement Occupational engagement is described as continuing to remain involved in vocational activities such as volunteering or education (Cosco et al., 2015) into the golden years. Stevens-Ratchford and Cebulak (2004) examined the benefits of engaging in occupations, using a small sample of older adults with arthritis. The researchers concluded that participants who remained actively engaged in social occupations reported better health, general well-being, and increased life satisfaction (Stevens-Ratchford & Cebulak, 2004). In another sample of older adults with physical limitations (rheumatoid arthritis), Zautra, Hamilton, and Yocum (2000) found that continued social engagement aided in decreasing stress. As appealing as the idea of volunteering or continuing to work after retirement may be to some, Cosco et al. (2015) found that many participants in their study felt vocationally fulfilled after retirement and therefore did not value occupational engagement as important. However, it is important to note that there is a serious shortfall of research on older Latino adults and occupational engagement. 1.5.3 Social Engagement/Social Network The idea of social engagement is being recognized as crucial to aging successfully (Mendes de Leon, 2005) and is emphasized in every component of engagement with life. 15 The literature on aging documenting a positive association between social engagement and aspects of well-being, such as physical, mental and cognitive functioning, and perceived quality of life is extensive (Cosco et al., 2015; Martinez, Kim, Tanner, Fried, & Seeman, 2009; Mendes de Leon, 2005; Rodriguez-Galan & Falcon, 2010). Engaging socially can be represented in a variety of contexts; for example, a marriage, family, and/or a social network in which new relationships could emerge (Cosco et al., 2015). The literature on social engagement among Latino elders has emphasized the importance of a social network that is inclusive of family and friends (Rodriguez-Galan & Falcon, 2010). Numerous studies also have examined the use of formal social services (i.e., health care-related services) and involvement in social activities among this population. For example, Freidemberg (1998) studied the relationship between social networks and health care among a group of elderly Latinos in New York and found that a strong social network predicted more frequent use of health care services and greater likelihood of addressing medical needs. Most studies of social engagement among Hispanic older adults have examined the role of social networks as a predictor of a health outcome or health seeking-behavior (Rodriguez-Galan & Falcon, 2010). The results of these investigations show that social engagement and supportive social networks help older Hispanics seek the help they need and maintain a healthier lifestyle (Angel & Angel, 2005; Dean, Kolody, & Wood, 1990; Freidemberg, 1988). 1.5.4 Social Support Cosco et al. (2015) described social support as an extension of social engagement focusing mainly on friends and family. The National Institute on Aging suggests 16 provision of social support and continued involvement in activities to foster positive effects on health and longevity in older adults (Banerjee, Perry, Tran, & Arafat, 2010). Social support research has shown positive effects on older adults’ general health (White, Philogene, Fine, & Sinha, 2009), physical functioning (Shaw, 2005), and overall life satisfaction (Newsom & Schulz, 1996). Russell and Taylor (2009) found that social support moderates the relationship between older adults living alone and symptoms of depression. Older adults who live alone seem to have different social support systems and perceive higher emotional support than their partnered counterparts (Barrett, 1999; Russell & Taylor, 2009). Latino culture is somewhat different from other ethnic groups because of the value placed on family, extended family, and friends. While some studies suggest that the social support systems of older Latinos can buffer the effects of stress (Russell & Taylor, 2009; Wilmoth, 2001), other studies suggest that social support can increase stress (Monserud & Markides, 2017). A study conducted on older adults of Mexican descent by Monserud and Markides (2017) concluded that social support and church attendance each play a very distinct role in managing depressive symptoms. While social support increased stress among a group of Mexican American widows, church attendance appeared to buffer the perceived stress (Monserud & Markides, 2017). 1.6 Current Study This study adopted Rowe and Kahn’s model of successful aging while incorporating new dimensions that previously have been overlooked in the literature. No studies have exclusively measured the typical panoply of variables that have been 17 specifically designed with the goal of identifying markers of “successful aging” and how these are interpreted from a Mexican worldview. Furthermore, previous research has entirely overlooked the significance of acculturation factors in relation to such views about aging well and the paradigm of successful aging in particularly. These studies have been limited in their use of heterogeneous ethnic groups as there is as much variability in attitudes within an ethnic group as there is between them (Ramirez, 1984). Rogers (2010) suggested that as individuals age, their perceptions change as they adapt to new situations and environments; therefore, acculturation as part of a culture could impact the way people define aging. The present study investigated the role of acculturation within the context of the Successful Aging Model in a sample of Mexican adults aged 55 and older that were either bilingual in (1) Spanish and English or were (2) primarily Spanish speaking. Specifically, this study focused on Mexican older adults’ beliefs about the importance of various attributes that undergird successful aging ideology, as these were identified in the literature (Phelan et al, 2004; Rowe & Kahn, 1997). The following research questions and hypothesis were generated based on this premise: Research Question 1: Are perceptions of aging well among older adults of Mexican origin with higher levels of acculturation associated with greater endorsement of attributes contained in the successful aging paradigm? Research Question 2: Do older adults of Mexican origin with a higher level of acculturation report better physical health than less-acculturated individuals? Research Question 3: Do older adults of Mexican origin with a higher level of acculturation report more social support than less-acculturated individuals? 18 The Short Acculturation Scale for Hispanics (SASH) was used to measure acculturation (Marín, Sabogal, VanOss, Otero-Sabogal, & Perez-Stable, 1987). A 20-item survey titled, “Your Ideas About Growing Older,” (YIAGO) developed by Phelan et al. (2004) was used to measure the physical, functional, psychological, and social dimensions of successful aging in the literature (Fernandez-Ballesteros et al., 2010). Components of functional health and well-being were measured using the Short Form-12 Health Questionnaire (Ware, Kosinski, & Keller, 1996). An abbreviated version of the Lubben Social Network Scale (Lubben & Gironda, 2004) measured social support. Based on the literature reviewed, the expectation for this study was that older adults with high and low levels of acculturation would exhibit different patterns of responses on measures relating to aging, health, and social support. Unlike much of the existing research that has examined national or ethnic differences in general, the present study focused on variations within a single Latino group, older adults of Mexican origin. CHAPTER 2 METHODOLOGY 2.1 Participants Participants were adults of Mexican descent aged 55 and older that were either bilingual in Spanish and English or were primarily Spanish-speaking. Participants were recruited by means of advertisements placed in the community both in the Los Angeles area in California and the Las Cruces area in New Mexico. For eligibility in the study, participants must have been age 55 or older, of Mexican origin, and fluent in English and/or Spanish. Participants who could not read or write Spanish and/or English, or those who attained less than a fourth-grade reading level were excluded from the study. Participants who displayed limited mobility in their primary writing arm were excluded. Participants who failed to complete all parts of the survey were removed from the data set prior to analysis. Individuals were not screened for any criterion beyond those stated above; therefore, no one was excluded based on sex, sexual orientation, or marital status. 2.2 Measures 2.2.1 Acculturation The Short Acculturation Scale for Hispanics, or SASH, is a 12-item self-report instrument that is scored on a five-point Likert-type scale. The scale identifies Hispanics 20 who are low or high in acculturation through the measurement of three related factors: language use, media, and ethnic social relations. SASH items measure differences of acculturation among several Hispanic subgroups, which can be administered in either Spanish or English. The primary focus of this measure is on language, which also tends to be one of the more important factors in predicting healthcare access behaviors. According to Abraido-Lanza (1997), the SASH has been used to examine acculturation in health promotion and prevention, particularly among older adults. Yamada et al. (2006) conducted a study to review 15 different measures of acculturation among the Hispanic population and rated the SASH as having sufficient reliability and validity for use in studies with older Latinos. Furthermore, this scale has shown a high degree of internal consistency as indicated by a coefficient alpha of 0.92 in a heterogeneous sample of Latino subgroups (Mexicans, Cubans, Puerto Ricans, and Central Americans) between the ages of 15-75. Reliability coefficients of 0.90, 0.86, and 0.78 also were obtained by all three related factors: language use, media, and ethnic social relations (Marín et al., 1987; Yamada et al., 2006). Alternate form reliability was established through a comparison of scores for both versions of this scale (r = .65; Yamada et al., 2006). 2.2.2 Successful Aging Successful aging was measured using a 20-item survey, “Your Ideas About Growing Older,” developed by Phelan et al. (2004). The original survey instrument consisted of a two-part questionnaire that measures specific attributes characterizing successful aging that have been identified and abstracted from the published successful 21 aging literature. The first part consists of a series of questions that asks participants their thoughts about aging, or aging successfully, and whether their thoughts about aging successfully have changed over the last 20 years. The second portion consists of 20 questions relating to attributes of successful aging as characterized in the literature. For the present study, participants were asked to respond to only the 20 items that were scored using a four-point Likert-type scale. The scale ranged from 1 (very important) to 4 (not at all important). The survey initially administered by Phelan et al. was normed on a group of Japanese-Americans and a group of Caucasians both over the age of 65. In that study, the “Your Ideas About Growing Older” survey demonstrated adequate psychometric properties. In a follow-up study, Fernandez-Ballesteros et al. (2010) translated this measure and administered it to older adults in seven Latin American countries and three countries in Europe. The questionnaire demonstrated overall excellent reliability with alpha coefficients at 0.89 (Fernandez-Ballesteros et al., 2010). 2.2.3 Subjective Health Attributes of functional health and well-being were measured using either the English or Spanish version of the Short Form-12 Health Questionnaire (SF-12). The measure was completed in either language based on the participant’s preference. The SF12 health survey was developed in 1994 as a shorter alternative to the SF-36 (Ware, Kosinski, & Keller, 1996). The SF-12 contains 12 items derived from the SF-36, including one or two items from each of the eight SF-36 subscales used to measure overall physical and mental health. The subscales include physical functioning, role 22 limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health (Cunillera et al., 2010). These 12 items were used to construct the Physical Component Summary (PCS) and the Mental Component Summary (MCS), which were based on standardized scores derived from the U.S. general population (Ashing-Giwa, Kim, & Tejero, 2008; Cunillera et al., 2010). Scores for each subscale range from 0-100, with higher scores indicating better functioning (Martin, Fiorentino, Jouldjian, Josephson, & Alessi, 2010). Both component scales of the SF-12 showed a high degree of internal consistency as indicated by coefficient alphas 0.89 and 0.90, respectively. The SF-12 has been translated and validated in several languages and has been found to be valid and reliable for the general population, with applicability to both cross-cultural populations and older adults (Cunillera et al., 2010). Much like the English version, the Spanish version of the SF-12 has shown a high degree of internal consistency as indicated by a coefficient alpha of 0.71 and test-retest reliability coefficients ranging from 0.58 to 0.99 (Alonso, Prieto, & Anto, 1995). In a follow up study, Alonso et al. (1998), compared norms for the Spanish version of the SF-12 Health Survey with norms from the U.S. questionnaire in a population aged 18 and older. Internal consistency levels were good to excellent with alpha coefficients ranging from 0.78 to 0.96. 2.2.4 Social Support An instrument that has been widely used to assess social integration and screen for social isolation in older adult populations is the Lubben Social Network Scale (LSNS; Lubben, 1988; Lubben et al., 2006). The original version of the LSNS is a 10-item scale 23 that has been translated into many languages and applied to older adult populations of diverse ethnic backgrounds. An abbreviated version of the LSNS was developed by Lubben and Gironda (2004) to screen for social isolation in practice settings. The LSNS-6 includes six questions; three questions that evaluate family ties and three questions that evaluate friendship ties. The following three questions are repeated alternately using the words “relatives” and “friends” for a total of six questions: How many relatives (or friends) do you see or hear from at least once a month? How many relatives (or friends) do you feel close to such that you could call on them for help? How many relatives (or friends) do you feel at ease with that you can talk about private matters? (Lubben et al., 2006). Each question was scored on a 0 to 5 scale with a total range from 0 to 30. Higher scores indicated larger social networks. A validation study conducted in three European cities with a sample of 7432 older men and women found an overall Cronbach alpha of 0.83 that was consistent across all cities (Lubben et al., 2006; Rubenstein, Lubben, & Mintzer, 1994). In a study exclusively with older women, the psychometric properties of the two subscales of the LSNS-6 yielded Cronbach alpha values of 0.86 for the family subscale and 0.82 for the friend subscale (Lubben, Blozik, & Gillmann, 2006). 2.2.5 Demographics A comprehensive demographic questionnaire was included in the survey packet with questions pertaining to the participant’s sex, age, marital status, progeny, housing, income, and education. Education was assessed in a two-part question. In the initial part 24 participants were asked to state their highest level of education completed. The categories were as follows: 1 (no schooling), 2 (elementary/1 st – 6th grades), 3 (junior high school/7th – 9th grades), 4 (high school/10th – 12th grades), 5 (some college), and 6 (graduate school). The second part asked participants to select the country (United States or Mexico) where they received their primary schooling. Additionally, to assess the number of years lived in the United States, participants were asked to select from the following five categories: 1 (less than five years), 2 (5 – 10 years), 3 (10 – 20 years), 4 (more than 20 years), or 5 (all my life). 2.3 Procedures G*power was used to determine the minimum sample required for the multiple regression analysis with two predictors. A minimum sample size of N = 67 subjects was required to detect a medium effect size of f2 = 0.30, with 80% power. Data were collected at a single point in time. Participants were recruited through flyers distributed and posted throughout the Los Angeles area in California and Las Cruces area in New Mexico at community churches and private organizations. Those expressing interest were contacted in person or by phone and were initially assessed to determine their age and ethnicity and their suitability to participate in the study (e.g., whether they were literate). The initial interview required approximately five minutes to complete. The process for completing the initial screening interview was as follows: If determined eligible, participants were informed about the time and length of the survey completion phase. They also were told that no monetary compensation would be provided. Participants were informed that their participation was entirely voluntary and 25 that they could choose to discontinue participation at any point during the study. If participants gave verbal consent, they were given the option of taking the measures in either English or Spanish. If participants agreed to take part in this study, a sealed packet containing five questionnaires and a demographic information sheet in the language of their choice was provided. Participants were instructed to remove the seal on the envelope and were to assure that no identifying information appeared on any of the forms. Participants were informed that all the information would be kept confidential and in numerical, nonsequential form so as to maintain participant anonymity. Participants completed the Spanish or English packet, which included a brief demographic survey and five questionnaires in the following order: 1) Demographic survey, 2) the Short Acculturation Scale for Hispanics (SASH), 3) “Your ideas about growing older” questionnaire, 4) the Short Form 12 Health Survey, and 5) the Lubben Social Network Scale (LBSN-6). Completion of the survey took approximately 40 minutes. After the survey was completed, the participants returned the materials to the packet and return the packet to the researcher. Then, they were thanked for their participation. The statistical software suite SPSS was used to conduct the analysis of the resulting quantitative data. The data collection and analysis steps are summarized in Table 2.1. Descriptive statistics for the variables were reported. Frequency and percentages summary were obtained for categorical variables, while the measure of central tendencies of means, standard deviations, and minimum and maximum values were computed for continuous variables. Correlational analyses were conducted to determine the interrelationships among 26 acculturation, perceptions of aging, physical measure of health, and social activity engagement. Statistical significance was determined by p values equal to or less than 0.05. Multiple regression models were used to determine the association between acculturation and perceptions of aging, acculturation and physical health, and acculturation and social support, while controlling for age in each model. The normality assumption was assessed through kurtosis and skewness statistics, as well as visual inspection of histograms. 27 Table 2.1 Summary of Data Analysis and Collection Process Step Step 1 Step 2 Step 3 Step 4 Step 5 Information about steps taken Clean data by removing incomplete data as well as data not meeting the inclusion criteria Calculate descriptive statistics, including demographic statistics Assess scatter plots for linear relationships Conduct correlation analysis to examine relationships between measures Perform hierarchical multiple regression CHAPTER 3 RESULTS The purpose of the present study was to evaluate the role of several variables considered dimensions of successful aging. Specifically, the present study investigated the relationship between perceptions of aging and levels of acculturation in older adults of Mexican origin. Additionally, the relationship between level of acculturation and physical health was evaluated as was the relationship between acculturation and perceived social support. 3.1 Descriptive Analysis For this study, 73 potential participants filled out the questionnaire packets. Six packets were excluded from the data because some of the questionnaires were incomplete, so only 67 of the 73 potential participants completed the entire survey packet. These 67 participants represented the sample that was examined in this study. A total of 40 participants completed the packet in English and 27 completed the packet in Spanish. There were 27 (40.3%) males and 40 (59.7%) females, aged 55 to 88 years of age. Their number of children ranged from 0 to 7 and grandchildren ranged from 0 to 17. Most people had lived in the U.S for more than 20 years, and most people had at least a high school education (71.7%). Tables 3.1 through 3.4 present descriptive statistics for 29 the present sample of older Mexican and Mexican American adults. 3.2 Preliminary Analyses Table 3.5 presents means, standards deviations, observed ranges, and coefficient alphas of scores on all scales used in the present study. Lower scores on the SASH indicate less acculturation and higher scores indicate more acculturation. Lower scores on the YIAGO indicate more engagement in successful aging behaviors. A portion of the SF-12 was used to measure physical health, with higher scores indicating better physical health. The abbreviated version of the Lubben Social Network Scale was used to measure social support, with higher scores indicating larger social networks. Independent sample t-tests were conducted to compare scores between people who completed English and Spanish versions of the measures. There was a significant difference in the scores for those who completed English (M=41.03, SD=11.73) versus Spanish (M=22.33, SD=7.09) versions of the SASH; t(65)=7.41, p < 0.01, 2 = .458. Scores on the SASH for English responders were higher than those for Spanish responders, indicating that the former were more acculturated than the latter. No significant differences between scores for English (M=29.65, SD=8.79) and Spanish (M=26.96, SD=6.80) responders on the YIAGO (t(65)=1.34, p = 0.19) were found. Differences between scores for English (M=41.95, SD=12.02) and Spanish (M=43.26, SD=10.51) responders on the SF-12 (t(65)= -.46, p = 0.65) were nonsignificant. Finally, no significant difference was found between scores on English (M=30.40, SD=14.49) and Spanish (M=31.30, SD=11.92) responders on the Lubben Social Network Scale – Revised (t(65)= -.27, p = 0.79). 30 Bivariate correlations with acculturation were calculated for the scores on the SASH, the YIAGO, the SF-12 Physical Component Summary Score, and the Lubben Social Network Scale – Revised. The correlations are presented in Table 3.6. There were no significant correlations among the measures. 3.3 Evaluation of Statistical Assumptions Prior to testing predictions, the assumption of normality of residuals was first assessed through visual inspection of histograms, as well as skewness and kurtosis statistics. For each variable, the standardized residuals were calculated, and normality testing revealed no significant violations of the normality assumption. Histograms were approximately normally distributed, and skewness and kurtosis statistics divided by their standard errors were within +/- 3, which indicated approximate normality. In addition, visual inspection of boxplots indicated that there were no extreme outliers. Table 3.7 depict the results of tests of assumptions. 3.4 Primary Analysis To address each hypothesis, hierarchical regression analyses were performed. Hierarchical regression, a form of multiple regression, was used in this study in order to assess the systematic effects of selected predictor variables on a criterion variable. Hypothesis 1: Perceptions of aging well among older adults of Mexican origin with higher levels of acculturation will be associated with greater endorsement of attributes contained in the successful aging paradigm. This first step in the regression contained only the age variable that was controlled 31 for. This was not statistically significant (F(1, 65) = .177, p = .675). The next step in the model introduced acculturation. The resulting change in R2 was not statistically significant, F(1, 64) = .538, p = .486. Acculturation was not a significant predictor of perception of aging after controlling for age. Table 3.8 summarizes the analysis. Hypothesis 2: Older adults of Mexican origin with a higher level of acculturation will report better physical health than less-acculturated individuals. The first step in the regression controlled for the demographic variable of age. The bivariate relation between age and physical health was statistically significant, F(1, 65) = 6.700, p = .012, r2 = .093. In the next step, acculturation was added as a predictor in the regression model. The resulting change in R2 was not statistically significant, F(1, 64) = .098, p = .756. Acculturation was not a statistically significant predictor of physical health after controlling for age. Table 3.9 summarizes the analysis. Hypothesis 3: Older adults of Mexican origin with a higher level of acculturation will report more social support. This first regression equation contained only the demographic variable of age. The test was not statistically significant, F(1, 65) = .092, p = .763. Acculturation was then added to the model. The resulting change in F was not statistically significant, F(1, 64) = .935, p = .337. Acculturation was not a statistically significant predictor of perception of social support after controlling for age. Table 3.10 summarizes the analysis. 32 3.5 Exploratory Analysis Given that the original hypotheses were not confirmed, exploratory analyses were conducted to determine if the model of successful aging had components that related to acculturation. Principal components analysis with varimax rotation was used to identify subscales from the perceptions of aging measure. Varimax rotation was used in an attempt to maximize the dispersion of loadings within factors, allowing for a smaller number of variables to load highly on a single factor. Three independent component scales with eigenvalues greater than 1.0 emerged from the YIAGO measure. The items most heavily loading on the scales were summed to create subscales that were labeled as Cognitive, Physical, and Social. The items and factor loadings in each subscale are listed in Table 3.11. Correlation coefficients also were calculated between the SASH and each subscale created from the YIAGO. The results indicated no significant correlations between the SASH and any of the YIAGO subscales. In addition, because there was a significant difference in acculturation between respondents who completed English and Spanish versions of the SASH, a dichotomous variable that distinguished between individuals who completed English and Spanish versions was included with age as control variables in the multiple regression analyses. In no case was the resulting relation between the SASH and the outcome measure statistically significant after controlling for version and age. Finally, a series of independent sample t-tests were conducted to tests for sex differences. There were no significant differences between male (M=34.81, SD=13.65) and female (M=32.60, SD=13.76) respondents on the SASH measure; t(65)=0.65, p = 33 0.52. There were no significant differences in the scores for males (M=30.20, SD=7.41) and females (M=27.49, SD=8.45) on the YIAGO; t(65)=1.35, p = 0.18. Scores for males (M=41.11, SD=10.61) and females (M=43.39, SD=11.90) on the SF-12; t(65)= -0.80, p = 0.43 also yielded no significant differences. However, males scored significantly lower on the Lubben Social Network Scale (M=25.37, SD=12.54) than did females (M=34.40, SD=12.90); t(65)= -2.84, p = 0.01. 3.6 Summary No outliers were identified prior to the analysis. In addition, the assumptions of normality and linearity were assessed by means of skewness and kurtosis statistics, histograms, scatter plots and boxplots. No significant violations were identified. Pearson correlations were performed to assess the bivariate correlations between the variables acculturation, successful aging, physical health, and social support. All bivariate correlations were nonsignificant (p > .05). For the first research question, acculturation was not found to be a statistically significant predictor of perception of aging after controlling for age. Data pertinent to the second research question revealed that age correlated with physical health, but acculturation was not found to be a statistically significant predictor of physical health after controlling for age. For the third research question, acculturation was not found to be a statistically significant predictor of perception of social support after controlling for age. 34 Table 3.1 Children and Grandchildren Age Number of children Number of grandchildren N 67 67 67 Minimum 55 0 0 Maximum 88 7 17 Mean 64.4 3.1 3.7 Std. Deviation 8.7 1.7 4.5 Table 3.2 Marriage and Living Situation Marital Status Single Married Separated/Divorced Widowed Total Frequency 3 42 16 6 67 Percent 4.5 62.7 23.9 9.0 100.0 29 7 10 2 19 67 43.3 10.4 14.9 3.9 28.4 100.0 Who do you live with? Spouse/Partner Children or relatives Alone Other Marked more than one option Total Table 3.3 Number of Years Living in the United States Age Category 5 – 10 years > 20 years All my life Total Frequency 1 35 31 67 Percent 1.5 52.2 46.3 100.0 35 Table 3.4 Education Educational Level Frequency 1 11 7 29 17 2 67 No education or schooling Elementary/1st – 6th grades Junior high school/7th – 9th grades High school/10th – 12th grades Some college Graduate school Total Percent 1.5 16.4 10.4 43.3 25.4 3.0 100.0 Table 3.5 Instruments: Means, Standard Deviations, Observed Ranges, and Coefficient Alphas. Variable ACCULTURATION AGING HEALTH SOCIAL Mean 33.54 28.66 48.42 31.49 SD 13.59 8.03 10.73 13.57 Range 12-56 20-67 22-66 3-54  .96 .87 .89 .93 Table 3.6 Correlation Matrix Measure 1 2 3 4 1. ACCULTURATION 2. AGING .08 3. HEALTH .20 -.04 4. SOCIAL -.18 -.03 .10 Note. (N = 67 participants). ACCULTURATION = Short Acculturation Scale for Hispanics; AGING = Your Ideas About Growing Older; HEALTH = SF-12 Health Measure; SOCIAL = Lubben Social Network Scale Revised, *p < .05, and **p <.01. 36 Table 3.7 Skewness and Kurtosis Statistics N Statistic 67 67 67 YIAGO SF-12 Lubben Skewness Statistic Std. Error 1.973 .293 -.370 .293 -.225 .293 Kurtosis Statistic Std. Error 6.934 .578 -.840 .578 -.537 .578 Table 3.8 Model Summary for Hypothesis 1 Model R R Square Adjusted R Square Std. Error of the Estimate 1 .052a .003 -.013 8.149 b 2 .105 .011 -.020 8.178 a. Predictors: (Constant), Age b. Predictors: (Constant), Age, Acculturation c. Dependent Variable: Your Ideas About Growing Older Change Statistics R Square F df1 df2 Change Change .003 .177 1 65 .008 .538 1 64 Table 3.9 Model Summary for Hypothesis 2 Model R R Square Adjusted R Square Std. Error of the Estimate 1 .306a .093 .080 10.908 b 2 .308 .095 .067 10.984 a. Predictors: (Constant), Age b. Predictors: (Constant), Age, Acculturation c. Dependent Variable: Physical Health (SF-12) Change Statistics R Square F df1 df2 Change Change .093 6.700 1 65 .001 .098 1 64 37 Table 3.10 Model Summary for Hypothesis 3 Model R R Square Adjusted R Square Std. Error of the Estimate Change Statistics R Square F df1 df2 Change Change .001 .092 1 65 .014 .935 1 64 1 .038a .001 -.014 13.515 b 2 .126 .016 -.015 13.522 a. Predictors: (Constant), Age b. Predictors: (Constant), Age, Acculturation c. Dependent Variable: Lubben Social Network Scale Revised 38 Table 3.11 “Your Ideas About Growing Older” Subscales COGNITIVE “Adjusting to changes that are related to aging” .829 “Not feeling lonely or isolated” .679 “Having a sense of peace when thinking about the fact that I will not live forever” .557 “Continuing to learn new things” .524 .483 “Being able to meet all of my needs and some of my wants” PHYSICAL “Remaining in good health until close to my death” .884 “Remaining free of chronic disease” .773 “Staying involved with the world and people around me” .596 “Being able to make choices about things that affect how I age, like my diet, exercise, and smoking” * .580 “Living a very long time” .402 SOCIAL “Having friends and family who are there for me” .751 “Having no regrets about how I lived my life” .685 .495 “Feeling that I have been able to influence others’ lives” ** * Item loaded higher on physical than cognitive subscale. ** Item loaded heavier on social subscale than cognitive subscale. CHAPTER 4 DISCUSSION This last chapter is divided into five sections: summary, findings, limitations, implications of the present research, and future research. The first section will include a summary statement of the problem, summarize the literature, and review the methods used for this study. The second section will state the research questions tested, review the main findings, and provide interpretations for this study. The third section will discuss research limitations. The fourth section will discuss the implications of the findings of this study. The final section will include directions for future research. 4.1 Summary The older adult population in the United States has seen the largest increase in history. Currently, about 20% of this older adult population is represented by people who identify as Hispanic, the majority of whom are represented by Hispanics of Mexican origin (U.S. Census Bureau, 2010; U.S. Census Bureau, 2012). This rapid rise in a culturally diverse aging population leaves professionals without adequate tools to assess the health related concerns that may or may not be specific to an individual’s culture. This is why the work of Rowe and Kahn became a focal point in this present study. Their work suggests that people could achieve successful aging by engaging in healthy lifestyle 40 behaviors and interventions as a way to postpone the aging process (Pruchno, WilsonGenderson, & Cartwright, 2010; Rowe & Kahn, 1997). The motivation for the present research is the need for culturally sensitive approaches to promote successful aging among older adults of Mexican origin. The present study evaluated the relationship between acculturation and variables associated with successful aging among older adults of Mexican origin. It explored the relationship between levels of acculturation and (1) perceptions of aging, (2) physical health, and (3) social support. The sample used for this dissertation consisted of 67 older adults of Mexican origin (27 males, 40 females), with age ranging from 55 to 88. Over half of this sample had lived in the United States for more than 20 years, with a little fewer than half having lived in the United States all of their life. Most people had at least a high school education. The majority of the participants reported being married and living with their spouse or partner. Four surveys and a demographic questionnaire were included in a packet given to participants either in Spanish or English based on their language preference. The Short Acculturation Scale for Hispanics (SASH) was used to measure acculturation. “Your Ideas About Growing Older,” nicknamed YIAGO, measured the participants’ ideas about successful aging beliefs published in the literature. The SF-12 was used to measure physical health. The fourth measure, The Lubben Social Network Scale, was used to assess social support. Correlational analyses were conducted to determine the interrelationships among acculturation, perceptions of aging, physical measures of health, and social activity engagement. Multiple regression models were used to assess the 41 association between acculturation and each of the outcome measures, while controlling for age. Subsequent exploratory analyses attempted to determine if subcomponents of the perceptions of aging questionnaire correlated with acculturation. Additional analyses were conducted to determine if acculturation accounted for variance in any of the outcome measures after controlling for whether the respondent completed the English or Spanish versions of the self-report measures in addition to controlling for age. 4.2 Findings 4.2.1 Research Question 1 RQ 1: Are perceptions of aging well among older adults of Mexican origin with higher levels of acculturation associated with greater endorsement of attributes contained in the successful aging paradigm? Acculturation was not found to be a significant predictor of greater endorsement of attributes contained in the successful aging literature. Given that there was no previous research on the relationship between acculturation and successful aging among older Latinos, no comparison of results to other research could be made. However, there is literature on cultural factors that influence aging among Latinos. Specifically, Angel (2009) discussed barriers believed to affect successful aging in older adults of Mexican origin. Angel (2009) pointed out that although older Mexican American adults live longer, they experience poorer health due to factors relating to poverty, lack of access to healthcare, varying levels of English proficiency, and social competency in a new environment. Angel (2009) further stated that in communities that contain large percentages of minority populations, family support may serve as a protective factor from 42 certain negative health risks. Two prior studies captured perceptions of aging successfully from a Latino worldview using the “Your Ideas About Growing Older” questionnaire (YIAGO). Hilton, Gonzalez, Saleh, Maitoza, and Anngela-Cole (2012) examined perceptions of aging in a group of 60 Latino older adults from three western states in the United States. The majority of the participants in the Hilton et al. study were of Mexican descent and the results of their study suggested that Latinos view aging as a normal part of life. Hilton et al. (2012) further stated that rather than using the community as a source of emotional and physical support, Latinos enjoy being part of a community, meaning their value is placed more on collective rather than individualistic participation. The responses to questions in the study by Hilton et al. were answered from a framework that places more emphasis on family and friends and less on the self. The responses in the Hilton et al. 2012 study parallel those in a study conducted by Fernandez-Ballesteros et al. (2010). Fernandez-Ballesteros et al. (2010) administered a portion of the YIAGO survey to older adults in seven Latin American and three European countries. Of the 1189 participants, 252 were from Mexico. FernandezBallesteros et al. (2010) found that items relating to family, friends, health, and overall life satisfaction were rated higher among most of the Latin American countries compared to the European countries. Items regarding health and social aspects were noted as important for the Latino populations studies by Hilton et al. (2012) and Fernandez-Ballesteros et al. (2010), and there was evidence that culture played a significant role in successful aging in the study by Angel (2009). Therefore, the present study investigated the relationships among these 43 variables. The hypothesis that acculturation would account for variance in perceptions of successful aging as measured by the YIAGO questionnaire was not confirmed 4.2.2 Research Question 2 RQ 2: Do older adults of Mexican origin with a higher level of acculturation report better physical health than less-acculturated individuals? The results indicated that the participants’ level of acculturation did not predict better physical health as measured by the SF-12. This null result was surprising since other investigators have reported significant correlations between acculturation and physical health in older Latino groups. For example, Todorova et al. (2013) found that higher acculturation was significantly linked with better self-reported health and fewer chronic medical conditions in a sample of 1357 primarily Spanish-speaking Puerto Rican older adults. Buscemi et al. (2012) measured acculturation and health in a sample of older Hispanic adults, primarily comprised of Cuban Americans using a shortened version of the SF-12, the measure of physical health used in this dissertation. The results of their study indicated that their sample of Hispanic older adults with higher levels of acculturation reported better physical and mental health (Buscemi et al., 2012). In contrast to the findings reported by Todorova et al. (2013) and Buscemi et al. (2012), Chavez-Korell et al. (2014) found that more acculturated older Latino adults were more depressed than less acculturated individuals; that is, acculturation was associated with negative health outcomes. They suggested that the density of Latinos in communities from which participants are sampled could moderate the relationship between acculturation and physical or mental health. In samples obtained from 44 predominantly Spanish-speaking neighborhoods, acculturation may be relatively low and positively related to health outcomes. In contrast, older Latino adults drawn from ethnically diverse neighborhoods may experience greater levels of stress, and the relationship between acculturation and health may be negative. In the present study, samples were drawn from relatively homogeneous communities of Latinos in Los Angeles, CA and Las Cruces, NM, and the relationship between acculturation and physical health was neither positive nor negative. Thus, the present sample may have been drawn from communities with more diversity than those of investigators who reported a positive relation between acculturation and health, but less diversity than those of other investigators who reported a negative association between acculturation and health. 4.2.3 Research Question 3 RQ 3: Do older adults of Mexican origin with a higher level of acculturation report more social support? The results showed no association between the participants’ level of acculturation and social support. This suggests that the level of the participants’ acculturation was not related to the dimensions of perceived social support as indicated by the scores on the Lubben Social Network Scale. It is challenging to compare the results of the present study with other studies in the literature for several reasons: 1) no studies have examined the relationship between acculturation and social support in a sample composed exclusively of older adults of Mexican origin; 2) there was little variability in acculturation among participants in the present sample; 3) most prior research on 45 acculturation and social support focused on adolescents and immigrant adults; and 4) measures other than the SASH and Lubben Social Network Scale were used in other studies that investigated the relationship between acculturation and social support. A few studies have looked at the role of social support independent of acculturation with older adults of Mexican origin. One study found that a strong social support network was correlated with improved cognitive functioning (Zamora-Macorra et al., 2017). Another study suggested that increased social support protected against increases in frailty among a group of older Mexican American adults (Peek, Howrey, Ternent, Ray, & Ottenbacher, 2012). Even fewer studies have examined the role of acculturation exclusively in older adults of Mexican origin (Gonzalez, Haan, & Hinton, 2001; González, Tarraf, & Haan, 2011; Salinas & Sheffield, 2009), none of which attempted to relate acculturation to levels of social support. It is well documented that Mexicans/Mexican Americans tend to have strong family support systems. However, the extent of the benefits of familial support among more or less acculturated older adults of Mexican origin needs to be further examined. Although improving social support networks among older Mexican adults could improve mental and physical health outcomes, the results of the present study suggest that efforts to acculturate this population may do little to raise their levels of social engagement. 4.3 Limitations Limitations encompass the potential weaknesses and barriers that a researcher could not control in the study (Leedy & Ormrod, 2015). The most serious limitation in the present study was the lack of acculturation variability in the sample. This sample was 46 highly acculturated, as indicated by the SASH measure. The majority of the participants had been living in this country at least 20 years, and many were fluent in English. The lack of variance in the factor of primary interest could explain the general failure to confirm any of the predictions made at the outset of the present investigation. Another related limitation might be that the measure of acculturation used in the present study was not adequate for this sample. Perhaps another measure of acculturation might relate more strongly with components of the successful aging model. One such measure is the 12-item short form of the Acculturation Rating Scale for Mexican Americans (Brief ARSMA-II), which was specifically designed to be used with Mexicans or Mexican Americans and is one of the most widely used measures of acculturation among the Latino population (Abraido-Lanza et al., 2017). However, it is important to note that measuring acculturation often proves challenging because no single measure can fully reflect differences in behaviors, values, social interaction, and physical health (Yamada, Valle, Barrio, & Jeste, 2006). External validity refers to the extent that study findings can be generalized to the larger population and applied to different settings. The present study included participants from two geographical locations, which led to the exclusion of people in other geographical locations with different experiences and opinions. Second, since participants were recruited from specific regions of the United States (Los Angeles and Las Cruces), caution should be exercised when attempting to generalize these findings to other Latino communities. And third, the present sample might not be reflective of other Mexican or Mexican American older adults’ beliefs about successful aging because the sample was composed primarily of acculturated, relatively educated (at least a high 47 school degree), and married women. Therefore, the results of this study may not generalize beyond these geographical locations and specific population. Finally, Leady and Ormrod (2015) define assumptions as the uncontrollable or unsubstantiated elements of a study included and accepted as true. The factors often lie beyond the control of the investigator and could affect results. In the case of the present study, several assumptions were made. The first assumption was that all the participants would understand the questions on the questionnaires and would offer honest responses to each question. Second, the study assumed that the data collection methods suited the investigation and provided an appropriate means of acquiring unbiased information regarding the relationship among the variables of the study. It is important to consider that the measurements used in this study may not have been appropriate for this particular sample. Although the methods used in the present study were similar to those used in prior published research on aging adults, questions may be raised about the participants’ biases and the fact that all measures were based on self-reports. 4.4 Implications To my knowledge, this dissertation was the first study to explore the role of acculturation in a sample of older adults of Mexican origin and their beliefs about successful aging and related behaviors. Despite the limitations noted above, the present study makes a contribution to the small amount of research focused on successful aging behaviors with culturally diverse samples. It is important to recognize the benefits of studying individual differences among members of a particular ethnic group to increase our understanding of the beliefs, opinions, and patterns of engagement in successful 48 aging behaviors that may be culture specific. If significant relationships among these variables can be established, the findings could prove beneficial for professionals in the field of mental health by guiding the adaptation of interventions and treatments to incorporate an individual’s culture and value system while providing services that are meaningful for their clients. Public health concerns associated with the increase of an older adult population also should be addressed, prevention being at the forefront. Many diseases and unfavorable health conditions experienced in older age could be prevented and perhaps even delayed by a change in lifestyle behaviors. Rowe and Kahn (1997) suggested that in older age, functional deterioration could be slowed or minimized (Versey, Stewart, & Duncan, 2013). Continuing to explore the impact of acculturation on successful aging from a Mexican worldview is recommended to increase public health awareness and develop strategies that help manage health-related concerns. Awareness is needed in order to help older adults understand the resources available to them. For example, community messages that promote healthy activities, social support groups, or gatherings where older adults could receive information about services available in their own language is a way to increase awareness about health to older adults. Developing social and activity programs aimed at early intervention and prevention is crucial in supporting the demands of an increasing older population (Teater & Baldwin, 2014). 4.5 Future Research Replicating this study with a larger Mexican or Mexican American sample that contains more variability in acculturation could contribute findings that support a more 49 holistic approach to successful aging. Efforts should be made to include participants from the extreme ends of the acculturation continuum to determine if there are clinically significant relations among measures of acculturation, health, and social support. Efforts should also be made to assess characteristics of the communities from which samples are drawn, since there is evidence that community characteristics moderate the relationships between acculturation and physical and mental health outcomes. Future research might consider using a mixed methods approach, such as that used by Hilton et al. (2012), to assess successful aging from a Mexican worldview to further understand these findings. In addition to including survey research questions, individual interviews could be included, much like Phelan and Larson did in their 2004 study, to explore personal meanings and interpretations about successful aging. The authors of both studies argued that face-to-face interviews are useful for gaining more valid responses from ethnic minority populations, especially when Spanish is the dominant language. Additionally, previous research suggests acculturation is a multidimensional construct, therefore incorporating a more current bidimensional scale of acculturation, in addition to measures of mental health and activities of daily life might reveal effects of acculturation. Another direction for future research in successful aging would be to investigate the role of spirituality or religiosity. Rowe and Kahn’s (1997) model of successful aging has received criticism for the lack of attention given to cultural components that impact the way an individual ages successfully, particularly the role of spirituality. Many studies have identified significant links between religion, spirituality, and health (George, Ellison, & Larson, 2002; Hill & Pargament, 2008; Seybold & Hill, 2001), with a few 50 finding similar associations among Latinos (Arredondo, Elder, Ayala, Campbell, & Baquero, 2005; Gillum, 2005). Future studies might examine effects of religious involvement and activity on components of the successful aging model in Mexican, Mexican American, and other aging populations. Moreover, religiosity could be compared from different levels of acculturation as it influences patterns of engagement in successful aging behaviors, such as physical health and social network involvement. Finally, there is a phenomenon documented in the literature called the “Hispanic health paradox.” Researchers have studied health differences between first-, second-, and third-generation Hispanics. They have found that, although first-generation Hispanics as a whole have lower socioeconomic status, they report better overall health when compared to second-generation Hispanics (Bostean, 2013; Viruell-Fuentes, 2007). Firstgeneration Hispanics also show a lower prevalence of diabetes, cancer, and hypertension when compared to second-generation Hispanics. Future research might compare firstand second-generation older adults of Mexican origin to determine if there are reliable differences between generations in their views about aging successfully, physical health, and social support. APPENDIX A ENGLISH MEASURES 52 Demographic Questionnaire 1. Male Female 2. What is your age: 3. What is your marital status: (Please check one) Single (never been married) Married Separated/Divorced Widowed 4. How many children do you have: 5. How many GRAND children do you have: 6. Who do you live with: (Please check all that apply) Spouse/Partner Children or relatives Alone Other: 7. How many years have you lived in the United States: (Please check one) Less than 5 years 5 – 10 years 10 – 20 years 53 More than 20 years All my life 8. What is your highest educational level completed: (Please check one) No Schooling Elementary School (1 st – 6th grade) specify: Junior High School (7th – 9th grade) specify: High School (10th – 12th grade) specify: College Graduate School Other (describe): 9. Where was your primary schooling: (Please check one) Mexico United States 10. How long ago did you see a doctor: (Month) (Year) 54 SASH - Short Acculturation Scale for Hispanics From: Marin, et al. (1987) Instructions: Read each item carefully and circle the number below each question that best answers the question for you. For the last four questions, non-Hispanic means African American, White, American Indian, Asian American, or any other person who is not Hispanic. 1. In general, what language(s) do you read and speak? 1 2 3 4 5 Only Spanish Spanish better than English Both Equally English better than Spanish Only English 2. What was the language(s) you used as a child? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 3. What language(s) do you usually speak at home? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 4. In which language(s) do you usually think? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 5. What language(s) do you usually speak with your friends? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 55 6. In what language(s) are the T.V. programs you usually watch? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 7. In what language(s) are the radio programs you usually listen to? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 8. In general, in what language(s) are the movies, T.V., and radio programs you prefer to watch and listen to? 1 Only Spanish 2 More Spanish than English 3 Both Equally 4 More English than Spanish 5 Only English 9. Your close friends are: 1 All Latinos/ Hispanics 2 3 More Latinos than Americans About equal 4 5 More Americans All than Americans Latinos 10. You prefer going to social gatherings/parties at which the people are: 1 All Latinos/ Hispanics 2 3 More Latinos than Americans About equal 4 5 More Americans All than Americans Latinos 11. The persons you visit or who visit you are: 1 All Latinos/ Hispanics 2 3 More Latinos than Americans About equal 4 5 More Americans All than Americans Latinos 56 12. If you could choose your children’s friends, you would want them to be: 1 All Latinos/ Hispanics 2 3 More Latinos than Americans About equal 4 5 More Americans All than Americans Latinos 57 Your Ideas About Growing Older Scale Modified version from: Phelan, E. A. & Larson, E. B. (2004) Instructions: Read each item carefully and circle the number that best describes how important each of the following statements is to you. 1. Living a very long time. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 2. Remaining in good health until close to death. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 3. Feeling satisfied with my life the majority of the time. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 4. Having the kind of genes (heredity) that help me age well. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 5. Having friends and family who are there for me. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 6. Staying involved with the world and people around me. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 58 7. Being able to make choices about things that affect how I age, like my diet, exercise, and smoking. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 8. Being able to meet all of my needs and some of my wants. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 9. Not feeling lonely or isolated. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 10. Adjusting to changes that are related to aging. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 11. Being able to take care of myself until close to the time of my death. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 12. Having a sense of peace when thinking about the fact that I will not live forever. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 59 13. Feeling that I have been able to influence others’ lives in positive ways. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 14. Having no regrets about how I have lived my life. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 15. Being able to work in paid or volunteer activities after usual retirement age. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 16. Feeling good about myself. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 17. Being able to cope with the challenges of my later years. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 18. Remaining free of chronic disease. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 19. Continuing to learn new things. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 60 20. Being able to act according to my own inner standards and values. 1 Very Important 2 Somewhat Important 3 A little Important 4 Not at all Important 61 SF-12 Answer every question by placing a check mark or “X” on the line in front of the appropriate answer. If you are unsure about how to answer a question, please give the best answer you can. 1. In general, would you say your health is: _____ Excellent (1) _____ Very Good (2) _____ Good (3) _____ Fair (4) _____ Poor (5) The following two questions are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much? 2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf: _____ Yes, Limited A Lot (1) _____ Yes, Limited A Little (2) _____ No, Not Limited At All (3) 3. Climbing SEVERAL flights of stairs: _____ Yes, Limited A Lot (1) _____ Yes, Limited A Little (2) _____ No, Not Limited At All (3) During the PAST 4 WEEKS have you had any of the following problems with your work or other regular activities AS A RESULT OF YOUR PHYSICAL HEALTH? 4. ACCOMPLISHED LESS than you would like: _____ Yes (1) _____ No (2) 5. Were limited in the KIND of work or other activities: _____ Yes (1) _____ No (2) 62 During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)? 6. ACCOMPLISHED LESS than you would like: _____ Yes (1) _____ No (2) 7. Didn’t do work or other activities as CAREFULLY as usual: _____ Yes (1) _____ No (2) 8. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work outside the home and housework)? _____ Not At All (1) _____ A Little Bit (2) _____ Moderately (3) _____ Quite A Bit (4) _____ Extremely (5) The next three questions are about how you feel and how things have been DURING THE PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS – 9. Have you felt calm and peaceful? _____ All of the Time (1) _____ Most of the Time (2) _____ A Good Bit of the Time (3) _____ Some of the Time (4) _____ A Little of the Time (5) _____ None of the Time (6) 10. Did you have a lot of energy? _____ All of the Time (1) _____ Most of the Time (2) _____ A Good Bit of the Time (3) _____ Some of the Time (4) _____ A Little of the Time (5) _____ None of the Time (6) 63 11. Have you felt downhearted and blue? _____ All of the Time (1) _____ Most of the Time (2) _____ A Good Bit of the Time (3) _____ Some of the Time (4) _____ A Little of the Time (5) _____ None of the Time (6) 12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)? _____ All of the Time (1) _____ Most of the Time (2) _____ Some of the Time (3) _____ A Little of the Time (4) _____ None of the Time (5) 64 LUBBEN SOCIAL NETWORK SCALE – REVISED (LSNS-R) FAMILY: Considering the people to whom you are related by birth, marriage, adoption, etc… 1. How many relatives do you see or hear from at least once a month? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 2. How often do you see or hear from the relative with whom you have the most contact? 0 = less than monthly 1 = monthly 3 = weekly 2 = few times a month 4 = few times a week 5 = daily 3. How many relatives do you feel at ease with that you can talk about private matters? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 4. How many relatives do you feel close to such that you could call on them for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 5. When one of your relatives has an important decision to make, how often do they talk to you about it? 0 = never 5 = always 1 = seldom 2 = sometimes 3 = often 4 = very often 65 6. How often is one of your relatives available for you to talk to when you have an important decision to make? 0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always FRIENDSHIPS: Considering all of your friends including those who live in your neighborhood… 7. How many of your friends do you see or hear from at least once a month? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 8. How often do you see or hear from the friend with whom you have the most contact? 0 = less than monthly 3 = weekly 1 = monthly 4 = few times a week 2 = few times a month 5 = daily 9. How many friends do you feel at ease with that you can talk about private matters? 0 = none more 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or 10. How many friends do you feel close to such that you could call on them for help? 0 = none 1 = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more 11. When one of your friends has an important decision to make, how often do they talk to you about it? 0 = never 5 = always 1 = seldom 2 = sometimes 3 = often 4 = very often 66 12. How often is one of your friends available for you to talk to when you have an important decision to make? 0 = never 5 = always 1 = seldom 2 = sometimes 3 = often 4 = very often APPENDIX B SPANISH MEASURES 68 Cuestionario Demográfico 1. Hombre Mujer 2. ¿Qué edad tiene?: 3. ¿Cuál es su estado civil?: (Verifique una opción) Soltero (nunca ha sido casado) Casado Separado/Divorciado Viudo 4. ¿Cuántos hijos tiene?: 5. ¿Cuántos nietos tiene?: 6. ¿Con quién vive usted?: (Verifique todas las opciónes que aplican) Esposo(a)/Compañero(a) Hijos o Familiares Sólo(a) Otro: 7. ¿Cuantos años tiene viviendo en los Estados Unidos?: (Verifique una opción) Menos de 5 años 5 – 10 años 10 – 20 años 69 Más de 20 años Toda mi vida 8. ¿Cuál es el grado más alto que ha completado en la escuela?: (Verifique una opción) No Educación Educación Primaria (1º – 6º) especifique: Educación Secundaria (1º - 3º) especifique: Educación Preparatoria (1º - 3º) especifique: Universidad Formación Profesional Otro: 9. Donde recibio la mayoría de su educación: (Verifique una opción) México United States 10. ¿Cuando fue la última vez que fue al médico?: (Mes) (Año) 70 Escala Corta de Aculturación para Hispanos (SASH) From: Marin, et al. (1987) Instrucciones:Lea cada artículo con cuidado. Indique o rodee el número debajo de cada pregunta que mejor responda la pregunta para usted. Para las cuatro últimas preguntas, “Americanos” se refiere a un Americano Africano, Blanco, Amerindio, Americano Asiático, o cualquier otra persona que no es Hispano/Latino. 1. ¿Por lo general, qué idioma(s) leé y habla usted? 1 2 3 4 Solo Español Español mejor que Inglés Ambos por igual Inglés mejor que Español 5 Solo Inglés 2. ¿Cuál fué el idioma(s) que habló cuando era niño(a)? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 3. ¿Por lo general, en qué idioma(s) habla en su casa? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 4. ¿Por lo general, en qué idioma(s) piensa? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 5. ¿Por lo general, en qué idioma(s) habla con sus amigos(as)? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 71 6. ¿Por lo general, en qué idioma(s) son los programas de televisión que usted ve? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 7. ¿Por lo general, en qué idioma(s) son los programas de radio que usted escucha? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 8. ¿Por lo general, en qué idioma(s) prefiere oir y ver películas, y programas de radio y televisión? 1 2 3 4 Solo Español Más Español que Inglés Ambos por igual Más Inglés que Español 5 Solo Inglés 9. Sus amigos y amigas mas cercanos son: 1 2 3 Solo Latinos Más Latinos que Americanos Casi mitad y mitad 4 Más Americanos qué Latinos 5 Solo Americanos 10. Usted prefiere ir a reuniones sociales/fiestas en las cuales las personas son: 1 2 3 Solo Latinos Más Latinos que Americanos Casi mitad y mitad 4 Más Americanos qué Latinos 5 Solo Americanos 72 11. Las personas que usted visita o que le visitan son: 1 2 3 Solo Latinos Más Latinos que Americanos Casi mitad y mitad 4 Más Americanos qué Latinos 5 Solo Americanos 12. Si usted pudiera escoger los amigos(as) de sus hijos(as), quisieran que ellos(as) fueran: 1 2 3 Solo Latinos Más Latinos que Americanos Casi mitad y mitad 4 Más Americanos qué Latinos 5 Solo Americanos 73 Sus Opiniones Sobre El Envejecimiento Modified version from: Phelan, E. A. & Larson, E. B. (2004) Instrucciones: Lea cada artículo con cuidado. Indique o rodee el número debajo de cada pregunta que mejor responda la pregunta para usted. 1. Vivir muchísimo tiempo. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 2. Mantenerme bien de salud hasta morir. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 3. Sentirme satisfecho(a) con mi vida la mayoría del tiempo. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 4. Tener por herencia el tipo de genes que me ayuden a envejecer bíen. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 5. Tener amistades y familia que me apoyen. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 74 6. Mantenerme activo(a) en el mundo y con las personas a mí alrededor. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 7. Poder seleccionar las cosas que afectan cómo yo me envejezco, por ejemplo, mi dieta, el ejercicio, y el fumar. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 8. Poder cumplir todas mis necesidades y algunos de mis deseos. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 9. No sentirme soló(a) o aisló(a). 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 10. Ajustarme a cambios relacionados con el envejecimiento. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 11. Poder cuidarme yo mismo(a) hasta cerca de morrir. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 75 12. Tener un sentido de paz al pensar del hecho que no viviré para siempre. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 13. Poder sentir que he influido las vidas de otras personas en maneras positivas. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 14. No tener pena acerca de cómo he vivido mi vida. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 15. Poder trabajar en actividades pagadas o de voluntario(a) después de la edad de jubilación usual. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 16. Sentirme bien acerca de yo mismo(a). 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 17. Poder enfrentar los desafíos de mis años posteriores. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 76 18. Mantenerme libre de las enfermedades crónicas. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 19. Continuar aprendiendo cosas nuevas. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 20. Poder actuar de acuerdo con mis propios estándares interiores y mis valores. 1 2 Muy Importante Algo Importante 3 Un Poco Importante 4 No es Importante 77 SF-12 (Spanish) INSTRUCCIONES: Las preguntas que siguen se refieren a lo que usted piensa sobre su salud. Sus respuestas permitirán saber como se encuentra usted y hasta qué punto es capaz de hacer sus actividades habituales. Por favor, conteste cada pregunta marcando una casilla. Si no está seguro/a de cómo responder a una pregunta, por favor, conteste lo que le parezca más cierto. 1. En general, usted diría que su salud es:    Excelente Muy Buena Buena  Regular  Mala Las siguientes preguntas se refieren a actividades o cosas que usted podría hacer en un día normal. Su salud actual, ¿le limita para hacer esas actividades o cosas? Si es así, ¿cuánto? 2. Esfuerzos MODERADOS, como mover una mesa, pasar la aspiradora, jugar a los bolos, o caminar más de 1 hora: _____ Sí, me limita mucho (1) _____ Sí, me limita un poco (2) _____ No, me limita para nada (3) 3. Subir varios pisos por la escalera: _____ Sí, me limita mucho (1) _____ Sí, me limita un poco (2) _____ No, me limita para nada (3) Durante las 4 últimas semanas, ¿ha tenido alguno de los siguientes problemas en su trabajo o en sus actividades cotidianas, a causa de su salud física? 4. ¿Hizo menos de lo que hubiera querido hacer? Sí  No  5. ¿Tuvo que dejar de hacer algunas tareas en su trabajo o en sus actividades cotidianas? Sí  No  78 Durante las 4 últimas semanas, ¿ha tenido alguno de los siguientes problemas en su trabajo o en sus actividades cotidianas, a causa de algún problema emocional (como estar triste, deprimido, o nervioso)? 6. ¿Hizo menos de lo que hubiera querido hacer, por algún problema emocional? Sí  No  7. ¿No hizo su trabajo o sus actividades cotidianas tan cuidadosamente como de costumbre, por algún problema emocional? Sí  No  8. Durante las 4 últimas semanas, ¿hasta qué punto el dolor le ha dificultado su trabajo habitual (incluido el trabajo fuera de casa y las tareas domésticas)?      Nada Un poco Regular Bastante Mucho Las preguntas que siguen se refieren a cómo se ha sentido y cómo le han ido las cosas durante las 4 últimas semanas. En cada pregunta responda lo que se parezca más a cómo se ha sentido usted. Durante las 4 últimas semanas ¿cuánto tiempo... 9. Se sintió calmado y tranquilo?    Siempre Casi Muchas Siempre veces  Algunas veces  Sólo alguna vez  Nunca Durante las 4 últimas semanas ¿cuánto tiempo... 10. Tuvo mucha energía?     Siempre Casi Muchas Algunas Siempre veces veces  Sólo alguna vez  Nunca 11. Se sintió desanimado y triste?    Siempre Casi Muchas Siempre veces  Sólo alguna vez  Nunca  Algunas veces 12. Durante las 4 últimas semanas, ¿con qué frecuencia la salud física o los problemas emocionales le han dificultado sus actividades sociales (como visitar a los amigos o familiares)?      Siempre Casi Algunas Sólo Nunca siempre veces alguna vez 79 ESCALA DE RED SOCIAL DE LUBBEN – REVISADA (LSNS-R) FAMILIARES: Teniendo en cuenta a las personas con las que usted está relacionado ya sea por nacimiento, casamiento, adopción, etc…. 1. ¿Con cuántos parientes se encuentra o tiene noticias de ellos, por lo menos, una vez por mes? 0 = ninguno 1 = uno 2 = dos 4 = de cinco a ocho 3 = tres o cuatro 5 = nueve o más 2. ¿Con qué frecuencia se encuentra o tiene noticias del pariente con el que tiene más contacto? 0 = menos de una vez por mes 2 = algunas veces al mes 4 = algunas veces por semana 1 = mensualmente 3 = semanalmente 5 = diariamente 3. ¿Con cuántos parientes se siente lo suficientemente cómodo como para conversar sobre sus asuntos personales? 0 = ninguno 1 = uno 4 = de cinco a ocho 2 = dos 3 = tres o cuatro 5 = nueve o más 4. ¿A cuántos parientes siente lo suficientemente cercanos como para llamarlos cuando necesita ayuda? 0 = ninguno 1 = uno 4 = de cinco a ocho 2 = dos 3 = tres o cuatro 5 = nueve o más 5. Cuando uno de sus parientes tiene que tomar una decisión importante, ¿con qué frecuencia se lo comenta a usted? 0 = nunca 1 = rara vez 2 = a veces 4 = con mucha frecuencia 3 = con frecuencia 5 = siempre 6. ¿Con qué frecuencia uno de sus parientes está disponible para hablar cuando usted tiene que tomar una decisión importante? 0 = nunca 1 = rara vez 2 = a veces 4 = con mucha frecuencia 3 = con frecuencia 5 = siempre 80 AMISTADES: Teniendo en cuenta a todos sus amigos, inclusive a aquellos que viven en su vecindario… 7. ¿Con cuántos amigos se encuentra o tiene noticias de ellos, por lo menos, una vez por mes? 0 = ninguno 1 = uno 4 = de cinco a ocho 2 = dos 3 = tres o cuatro 5 = nueve o más 8. ¿Con qué frecuencia se encuentra o tiene noticias del amigo con el que tiene más contacto? 0 = menos de una vez por mes 1 = mensualmente 2 = algunas veces al mes 3 = semanalmente 4 = algunas veces por semana 5 = diariamente 9. ¿Con cuántos amigos se siente lo suficientemente cómodo como para conversar sobre sus asuntos personales? 0 = ninguno 1 = uno 4 = de cinco a ocho 2 = dos 3 = tres o cuatro 5 = nueve o más 10. ¿A cuántos amigos siente lo suficientemente cercanos como para llamarlos cuando necesita ayuda? 0 = ninguno 1 = uno 4 = de cinco a ocho 2 = dos 3 = tres o cuatro 5 = nueve o más 11. 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