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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 10 The Role of Social and Personal Resources in Ethnic Disparities in Late-Life Health Carlos F. Mendes de Leon and Thomas A. Glass The past three decades have witnessed a proliferation of research on overall health and well-being of the oldest segments of the population, generally defined as adults aged 65 years and over. An important theme of this research has been to document the existence of disparities in health and well-being across groups defined by race/ethnicity or socioeconomic status (SES) (National Research Council, 1997). As described in detail elsewhere in this volume (see Chapter 3 by Hummer), minority seniors have, on average, higher mortality rates and poorer self-ratings of health (Ferraro and Farmer, 1996; Hummer, 1996), as well as a higher prevalence of physical disability and cognitive function, when compared with the majority population of non-Hispanic whites (Fillenbaum et al., 1998; Froehlich, Bogardus, and Inouye, 2001; Mendes de Leon et al., 1995, 1997; Tang et al., 1998). Increasingly, the field has moved toward a deeper understanding of the mechanisms and processes that lead to these disparities. In this chapter, we consider the role of personal and social resources in explaining the origins and consequences of racial/ethnic disparities in late-life health. From a lifespan developmental perspective, individuals actively regulate personal and social resources as they “age” for the purpose of personal growth and adaptation (Baltes and Lang, 1997; Lang, 2001; Lang, Featherman, and Nesselroade, 1997; Ryff, 1991). This process is modulated in important ways by the sociocultural environment, which, through prevailing norms, values, and expectations, shapes and reinforces an individual’s resources that optimize adaptation (Verbrugge and Jette, 1994). These contextual influences are likely to differ substantially across racial and ethnic groups because race and
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life ethnicity are critical determinants of the residential segregation and social stratification that characterize American society. The relatively unique social experiences and conditions of racial and ethnic sub-populations may lead to important variations in the personal and social resources that are accumulated throughout life. Thus, to the extent that they affect age-related health and well-being, variations in these resources may be an important aspect of understanding and alleviating ethnic disparities in late-life health. TOWARD A CONCEPTUAL FRAMEWORK For the purpose of this chapter, we will conceptualize social and personal resources as a series of assets that accrue to individuals as a result of their linkages or interactions with other individuals. The focus will be on those resources that have received the attention of social gerontologists and that are hypothesized to be associated with tangible health benefits. Investigation of these resources may help us to achieve a deeper understanding of the origins of health disparities across race/ethnic lines in late life. Figure 10-1 presents FIGURE 10-1 Conceptual model of the impact of personal resources on health outcomes. SOURCES: House (1987), Pearlin (1985), and Link and Phelan (1995).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life an organizing framework for understanding the role of social and personal resources in the cascade of social and individual-level processes that affect health. This framework will be used as a tool to organize existing literature, and to identify gaps in this literature and future opportunities. The framework maps a series of conceptually distinct factors that are arranged to represent, from left to right, the spectrum of upstream, distal (or fundamental) causes of health (see Link and Phelan, 1995), to intermediate causes of health at the level of social and personal resources, to a series of mechanisms more proximate to health and disease. Although this sequence of influences corresponds broadly to an underlying temporal or causal model of social and individual-level influences on health, it is likely that the actual causal processes involve a greater degree of complexity than this framework suggests. The figure is designed to underscore the broader social and biological context in which social and personal resources are related to health (House, 1987; Pearlin, 1985). Although we will classify the resources reviewed in this chapter on the basis of their “social” or “personal” nature, the boundaries between these two sets of resources are somewhat artificial. Social resources, categorized here into social and community networks, emphasize the social or structural nature of the asset. These assets may be considered a resource because they provide the potential conduits through which personal resources are accessed or activated. Personal resources, on the other hand, encompass assets that place primary emphasis on the individual, even if the asset has an inherent social dependency. This chapter will focus on two types of personal resources, social engagement and social support. It is important to note that our conceptualization of social and personal resources is somewhat restrictive, and that there are other such resources with important health benefits. For example, assets attributable to social class or social position, such as political and economic assets, are important personal resources associated with significant health disparities. The role of such socioeconomic resources in ethnic disparities in late-life health is reviewed in Chapter 9. Personal resources may also be conceptualized in terms of psychological attributes that have been linked with health outcomes. Their role is reviewed in further detail in Chapter 13. Although we will briefly discuss the influence of neighborhood characteristics in late-life health, a more extensive discussion of this topic can be found in Chapter 11. The remainder of this chapter will focus on differences in the patterning of social and personal resources as already defined across race and ethnic groups, as well as their differential impact on late-life health. A Comment on the Term “Race” Much has been written about the use and misuse of the concepts of race and ethnicity in health research (Kaufman and Cooper, 2001; Muntaner,
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Nieto, and O’Campo, 1996; Witzig, 1996). In the context of this chapter, these concepts are used as an indicator of a “social” reality, rather than pertaining to some underlying biological dimension (Goodman, 2000; Williams, Lavizzo-Mourey, and Warren, 1994). When addressing racial/ethnic disparities in health, one is usually presented with the inevitable dilemma of selecting one group to serve as a reference for comparisons between persons of differing racial/ethnic backgrounds. In most of the literature on this topic, that group is the dominant or majority sub-population of non-Hispanic whites. While this choice may have important scientific and social ramifications, for the purpose of convenience, we will adopt the same approach in this chapter. The remainder of the chapter is divided into three sections. In the second section, we will review the evidence regarding the differential distribution of social and personal resources by race and ethnicity. In the third section, we will examine the degree to which racial/ethnic differences in social and personal resources may contribute to disparities in late-life health. In the final section, we will briefly describe some of the mechanisms that have been postulated to link these resources to health processes, and present some information on possible intervention strategies. Next, we will identify important gaps in our understanding of the role of social and personal resources in ethnic disparities in late-life health, and discuss some of main methodological challenges that have hampered progress in this field. We will conclude with an overall summary of the findings, and an agenda for future research. DIFFERENCES IN SOCIAL AND PERSONAL RESOURCES AMONG OLDER ADULTS OF DIFFERENT RACIAL OR ETHNIC BACKGROUNDS Consideration of differences in the distribution of social resources across subpopulations defined by race or ethnicity is a first step toward a better understanding of the role of these resources in disparities in late-life health. For the purpose of this discussion, we will first review the evidence regarding racial/ethnic differences in the structural and compositional arrangements of the social and community networks of older adults. Next, we will turn our attention to the differential distribution by race/ethnicity of personal resources. These resources are further classified into social engagement, defined as participation in meaningful social activity, and social support. Social engagement itself is a relatively broad construct that consists of various forms of behavior that take place in a social context, including religious involvement, social activity, and productive activity (activities that produce goods and services with economic value). Religious involvement will be defined based on both
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life participation in organized religious activities and personal religiousness or spirituality. Social Networks Social networks refer to the matrix of social relationships to which individuals are tied (Fischer, 1982). This matrix has structural and functional characteristics that constitute the social parameters of available resources. Social networks are generally characterized in terms of several categories, including the availability of ties (number, proximity, and accessibility of ties), the structural characteristics of those ties (density, multiplexity, and other factors), the composition of ties (with kin versus nonkin, friendships, and ties gained through formal organizational linkages), and the efficacy of those ties, or the ability of ties to facilitate the transfer of resources. At a community level, following the theoretical work of Wandersman and Nation (1998) and Glass and Balfour (2003), we differentiate three aspects of community networks (or neighborhoods and complex organizations) that are analytically distinct and appear to play a role in shaping the availability and effectiveness of personal resources. These include the physical characteristics of communities (e.g., graffiti, lighting, noise); the mediating institutions such as houses of worship, schools, and neighborhood organizations that link individuals to the larger social context (Berger and Neuhaus, 1977); the services available (both municipal and commercial); and the social organization of those communities (disorder, violence, crime, social capital, social cohesion). The exact effects of aging on changes in social networks in late life remain somewhat unclear. Some evidence indicates that networks tend to shrink due to loss of network members who have died (Antonucci and Akiyama, 1987; Morgan, 1988). These losses affect mostly peripheral members of the social network, resulting in smaller but denser social networks (Antonucci and Akiyama, 1987; Carstensen, 1995). However, some of these losses may be counterbalanced by replacement with new relationships, or by intensification of existing relationships (Martire, Schulz, Mittelmark, and Newsom, 1999; van Tilburg, 1998). For example, some have suggested that older adults tend to draw increasingly close to network members that are most likely to satisfy their emotional and tangible needs—usually their children or children-in-law, siblings, or other close kin (Carstensen, 1995; Field and Minkler, 1988; van Tilburg, 1998). In sum, there may be considerable stability in the overall size of social networks among older adults, even if the composition of network members changes as people age. Earlier gerontologic work suggested that older African Americans tend to have larger social networks compared with whites (Ball, Warheit, Vandiver, and Holzer, 1980; Taylor and Chatters, 1986a; Vaux, 1985).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Most of the racial differences in network size are due to older blacks having more children and being more integrated with extended family members (Gibson and Jackson, 1987; Johnson and Barer, 1990; Taylor, Chatters, Tucker, and Lewis, 1990). More recent studies have been less consistent in reporting differences in overall network size between blacks and whites, with some studies even reporting smaller networks for older blacks. For example, in a study of a biracial population in the Piedmont region of North Carolina, there were no differences in network size between blacks and whites, but blacks had slightly larger networks of children and relatives, whereas whites had larger networks of friends (Mendes de Leon, Gold, Glass, Kaplan, and George, 2001). A slightly larger children network was also noted among older blacks in the New Haven Established Populations for Epidemiological Studies of the Elderly (EPESE) Study, but no racial differences in overall network size were noted between blacks and whites (Glass, Mendes de Leon, Seeman, and Berkman, 1997). Data from the Cardiovascular Health Study revealed smaller networks of family and friends for blacks compared with whites, although the proportion of blacks in this study was very small (Martire et al., 1999). A similar pattern was found in a population-based study of older adults in Detroit. In that study, older blacks reported smaller networks, but more frequent contact with network members, closer proximity, and a greater proportion of close kin compared with whites (Ajrouch, Antonucci, and Janevic, 2001). There were also no substantial racial differences in the availability of informal caregivers. However, blacks tend to draw from a larger pool of more distant relatives when they are disabled than do whites (Burton et al., 1995; Thorton, White-Means, and Choi, 1993). Based on the available evidence, the overall pattern is that older blacks have similarly sized or slightly smaller social networks, but that these networks are more likely to include extended family and fictive kin (Ajrouch et al., 2001). These racial patterns in network size are further borne out by examining differences in living arrangements by race. Coresidence serves as an indicator of the proximity of social network ties. As shown in Table 10-1, among all persons aged 65 and over, blacks are much less likely to be living in the same household with their spouse than whites. Only 24.3 percent of black women and 53.5 percent of black men live with their spouse, compared with 42.4 percent and 74.3 percent respectively among whites. On the other hand, older blacks are more likely to live with other relatives or nonrelatives compared with whites. The net result is that black women are very comparable to white women in terms of living alone, at 40.8 percent and 41.3 percent respectively. On the other hand, older black men (24.9 percent) are slightly more likely to live alone compared to white men. Much less is known about the social network characteristics of other ethnic groups. Baxter and colleagues (1998) report no differences in net-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life TABLE 10-1 Living Arrangements of Persons Aged 65 and Older, 1998 Sex and Living Arrangements All Ethnicities White Black Hispanic Asian or Pacific Islander Women With spouse 40.7 42.4 24.3 36.9 41.3 With other relatives 16.8 14.8 32.2 33.8 36.7 With nonrelatives 1.7 1.6 2.7 1.8 0.8 Alone 40.8 41.3 40.8 27.4 21.2 Men With spouse 72.6 74.3 53.5 66.8 72.0 With other relatives 7.0 6.0 14.8 15.0 20.8 With nonrelatives 3.0 2.7 6.8 4.3 0.6 Alone 17.3 17.0 24.9 14.0 6.6 SOURCE: Federal Interagency Forum on Aging Related Statistics (2000). Older Americans 2000: Key Indicators of Well-Being. work size between older Hispanics and non-Hispanic whites who live in a mostly rural area. However, older Hispanics living in New York City reported more children and close relatives in their social networks compared to either blacks or whites, but significantly fewer distant relatives, friends, and other social contacts (Cantor, 1975; Cantor, Brennan, and Sainz, 1994). Table 10-1 provides some additional data on the living arrangements of older Hispanics and other ethnic groups. Both older Hispanics and Asian or Pacific Islanders are somewhat less likely to be living alone compared with whites and blacks. This is primarily because they are more likely to share a household with relatives other than a spouse. Thus, these data suggest that in terms of the most proximate social ties, older Hispanics and Asian and Pacific Islanders appear to have larger networks than either blacks or whites. However, there are insufficient data on other types of social relationships, particularly more discretionary types of ties that do not involve close kin. Thus, it is too early to make more conclusive inferences about differences in the size and composition of social network structures between these ethnic groups. Neighborhood Characteristics The availability of social and personal resources across racial/ethnic groups is partly conditioned by the stark differences that exist in the neighborhoods in which these ethnic groups live. Early studies by Lawton and Byerts (1973) demonstrate that older adults meet most of their social and daily needs within a six-block radius. Thus the features of the immediate neighborhood environment are important determinants of personal resources at the individual level. It is fairly clear that residential segregation by race/ethnicity is a common pattern in the United States that leads to stark differences in the social charac-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life teristics of neighborhoods in which various ethnic groups reside (LaVeist, 1993; Massey and Eggers, 1990). Residential segregation leads to differential forms of social organization that in turn are associated with variations in health status. For example, blacks tend to live in neighborhoods with higher rates of female-headed households, a characteristic that has been linked to higher rates of heart disease in women (LeClere, Rogers, and Peters, 1998). Ethnic minority elders tend to live in neighborhoods that also have higher crime and poverty rates, a finding that has important implications for both the need for and the availability of resources (Massey and Eggers, 1990). Differences in the character of neighborhoods where minority groups live have been used to explain some of the disparities in the health status of these groups (Kawachi and Kennedy, 1997; Waitzman and Smith, 1998). Social Engagement Research on the activity patterns of elderly persons shows considerable variation, with a substantial proportion of older persons remaining active well into their later years. Postretirement age has become widely accepted as a stage of continued engagement and personal growth (Glass, in press; Glass, Seeman, Herzog, Kahn, and Berkman, 1995; Ryff and Singer, 1998). Some studies suggest that older blacks are more actively involved in their networks compared with whites. For example, older blacks report more frequent contacts with network members (Ajrouch et al., 2001), particularly children and other relatives (Johnson and Barer, 1990; Mendes de Leon et al., 2001), which may be a function of their higher level of integration into family networks. Older blacks also are believed to engage in a more active flow of resources among network members. For example, several studies report that older blacks provide more support and assistance to others in their network compared with whites (Lee, Peek, and Coward, 1998; Miner, 1995). Other evidence suggests, however, that greater levels of social engagement among older blacks is not uniform. Using data from the National Survey of Family and Households (NSFH), Silverstein and Waite (1993) found that black adults are slightly less likely to be providers of instrumental support than whites, although these differences were somewhat attenuated in older ages. Hispanic adults were also less likely to be support providers compared with whites (Silverstein and Waite, 1993). Others have found no evidence that either blacks or Hispanics were more active agents of assistance and support in their respective networks (Cantor et al., 1994; Pugliesi and Shook, 1998). Both blacks and Hispanics have also been observed to be less involved in volunteer work compared with older whites (Baxter et al., 1998; Kincade et al., 1996). An important aspect of social engagement among older adults is participation in productive activity. Gerontologic research on productive activ-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life ity has challenged long-held beliefs, suggesting a substantial proportion of older persons remaining productive well into their later years. Herzog and colleagues (1987) found that productive activity declines on average with increasing age, but that controls for health status and education sharply reduce the magnitude of these age-related declines. In part, declines in productivity in older age result from the cessation of paid work and child care, while older adults remain as active as their younger counterparts in unpaid work, volunteerism, and informal help to others (Cutler, 1977; Herzog and Morgan, 1989; Herzog, Kahn, Morgan, Jackson, and Antonucci, 1989). A number of studies have pointed to the importance of race/ethnicity and gender as critical contexts in which to understand productivity among older adults (Danigelis and McIntosh, 1993; Herzog and Morgan, 1992). A recent systematic review of this topic was undertaken by Jackson (2001), who argues that engagement in productive activity is affected over the life course by both blocked opportunities and economic necessity. From that standpoint, racial and ethnic heterogeneity in patterns of participation in productive activity is to be reasonably expected. Among the findings from this literature is the importance of considering productive activities that fall outside traditional definitions of economic activity such as paid work and volunteering. Failure to do so risks underestimating the true economic value of those activities that nonwhite ethnic groups tend to participate in to greater extents, including caregiving (Chatters, Taylor, and Jackson, 1985; Taylor and Chatters, 1986a; Taylor and Taylor, 1982) and bartering (Stack, 1974). Given that participation in primary and secondary labor markets throughout the life course is less satisfactory to disadvantaged groups, it appears clear that continued participation in productive activity must be seen in a larger context. Studies that have attempted to include measures of activity participation that include informal and social forms of productivity generally have observed that blacks and whites demonstrate comparable degrees of continuity in late life (Antonucci, Jackson, Gibson, and Herzog, 1989; Glass et al., 1995; Jackson, 2001). Participation in productive activities may play an especially important role in maintaining identity in persons in disadvantaged groups because they perceive that their activities help to meet community needs (Deimling, Harel, and Noelker, 1983). Caregiving is another form of productive activity that is relatively common among the elderly. In a community-based study of older adults, blacks were 30 percent more likely to report caregiving compared with whites, after controlling for age, sex, marital status, and education (McCann et al., 2000). However, data from the National Survey of Self-Care and Aging did not show any racial differences in caregiving, although blacks were more likely to provide emotional support (Kincade et al., 1996). Data on caregiving in other ethnic groups is largely absent.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Another area of social engagement that has received considerable attention is participation in formal and informal organizations, especially those centered around religious activity. Participation in religious activity typically presents an opportunity for social interaction with others who are likely to have similar beliefs and values. In addition, it may provide an important conduit through which both personal and social resources are activated and maintained (Levin, Taylor, and Chatters, 1994). The importance of the church has long been a topic of particular interest in the unique history and social conditions of blacks (Chatters and Taylor, 1994). The seminal work by Taylor and Chatters has further underscored the centrality of church-related activity and religiosity in older black adults (Taylor, 1986; Taylor and Chatters, 1986a). This research has highlighted the significance of the church in black communities as a resource to adapt to the adverse life conditions and social disadvantage, and to provide opportunities for personal and spiritual growth and well-being (Chatters, 2000). Levin and colleagues (1994) undertook a systematic quantitative analysis of racial differences in church attendance and other indicators of religious engagement. They found only minor differences between older blacks and whites in levels of religious affiliation, as church membership was nearly 100 percent in both groups; however, blacks reported slightly higher levels of church attendance than whites. There were more pronounced racial differences in nonorganizational religious activity and subjective religiosity. For example, blacks were much more likely to read religious books and to listen to religious radio programs. They also rated their religion as being more important to them than older whites did. Other studies also have shown that older blacks tend to have higher levels of religious involvement than whites (Johnson and Barer, 1990; Kim and McKenry, 1998). In contrast, participation in other types of social or work-related organizations tends to be lower among blacks (Cutler and Hendricks, 2000; Miner and Tolnay, 1998). Fewer data are available on church-related activity and other forms of social engagement for other ethnic groups. A study of a rural Hispanic population showed patterns of engagement similar to those of older blacks. Participation in church-related groups was found to be higher, but involvement in other social groups and organizations was lower, among older Hispanics relative to non-Hispanic whites (Baxter et al., 1998). Social Support The social support needs of adults are likely to change as they enter the postretirement years. The need for financial assistance, for help with daily tasks as health declines, and for emotional support may all increase (Carstensen, 1995; Silverstein and Waite, 1993). Older adults of all racial/
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life ethnic groups tend to rely heavily on family members as the primary source of both instrumental and emotional support. Even so, help and assistance from immediate family or next of kin is thought to be more common among older blacks than older whites (Lee et al., 1998; Mutran, 1985). Cantor and colleagues (1994) report that both black and Hispanic children are more likely to provide practical and informational types of support to their aged parents than do white children. This could be partly because of the greater care needs of older blacks and Hispanics, who may be in poorer health. However, other research suggests that underlying differentials in health are not a sufficient explanation for the greater use of support among older blacks and other minority elders (Tennstedt and Chang, 1998). Instead, it has been suggested that older disabled whites tend to replace informal support with formal support services in times of poor health, whereas older blacks may acquire formal services in addition to the informal assistance they receive from family and friends (Miner, 1995). Overall, a picture has emerged of elderly blacks and Hispanics being more likely to benefit from cross-generational exchanges of supportive resources (Mutran, 1985). Similar patterns of intergenerational support also have been described for older Asian Americans, although there is considerable diversity in family relationships and support structures among Asian populations, depending on the country of origin. For example, elderly Koreans seem to rely more on their children for assistance and emotional support than do elderly Chinese or Japanese (Ishii-Kuntz, 1997). Several other studies, however, are less consistent with important ethnic/racial differences in social support among the elderly. For example, in the NSFH data, older blacks and Hispanic men were no more likely to receive instrumental or emotional support than non-Hispanics, while Hispanic women were significantly less likely to receive these two types of support (Silverstein and Waite, 1993). In another population-based study of older adults living in the Piedmont area of North Carolina, blacks reported slightly higher levels of instrumental support than whites, but there were no differences in emotional support (Mendes de Leon et al., 2001). In one of the few longitudinal investigations of social support changes in older adults, Martire and colleagues (1999) found no black-white differences in emotional, instrumental, or informational support, although blacks showed somewhat higher declines in informational support over time than whites. In conclusion, this review suggests there is little evidence for substantial differences by race or ethnicity in social and personal resources in older adults. In general, minority elders may have somewhat closer knit family networks compared to non-Hispanic whites, but possibly a smaller overall network, particularly with regard to more discretionary types of ties, such as friends. A similar pattern is apparent for social engagement. Overall, elderly whites appear somewhat more socially active, especially with regard
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Representative terms from entire chapter: