Older adults (aged 65 years and over) comprised approximately 15.2% of the U.S. population in 2016 and this number is projected to double by 2060 (Administration for Community Living, 2018). The projected increase is even more pronounced for ethnic minority groups (Colby & Ortman, 2015), especially in the older Asian American population (Ortman & Velkoff, 2014). Given this growth, interest in this group has heightened, with many studies being conducted with a focus on their psychological health and distress (see, e.g., Kuo, Chong, & Joseph, 2008; Mui & Kang, 2006).

Psychological distress refers to the presence of a nonspecific negative mental health state composed of multidimensional constructs, such as depression and anxiety (Kessler et al., 2002). The development of this distress is influenced by numerous factors, including sociodemographics, social relationships, and physical and functional health status (Paul, Ayis, & Ebrahim, 2006; Vink, Aartsen, & Schoevers, 2008). Health-related behaviors have also been identified as risk factors (Vink et al., 2008). Psychological distress among older adults is a significant public health concern in the US: the prevalence is estimated to range between 20% and 48% among community-dwelling older adults (Paul et al., 2006; Préville, Hébert, Bravo, & Boyer, 2002). Several researchers have reported that psychological distress is associated with increased risk of physical and functional impairments, and mortality (Hamer, Bates, & Mishra, 2011; Ormel, Rijsdijk, Sullivan, van Sonderen, & Kempen, 2002).

To date, scholars (e.g., Cole & Dendukuri, 2003; Djernes, 2006) have focused on identifying factors influencing psychological distress in older adults. The empirical evidence shows that these factors operate differently across ethnic groups (Jang, Borenstein, Chiriboga, & Mortimer, 2005). However, there are limited comparative studies of the differences between non-Hispanic White and Asian American community-dwelling older adults. Considering that Asian Americans are at higher risk for experiencing psychological problems than are non-Hispanic Whites (Mui & Kang, 2006; Okazaki, 2000), and that limited information exists on the risk factors for Asian Americans experiencing psychological distress, it is important to gain more knowledge about how this develops. To address this gap in current knowledge, we examined factors affecting psychological distress in older adult Asian Americans and non-Hispanic Whites using survey data in a population-based study.

Method

Source of Data

The California Health Interview Survey (CHIS; 2017) is a population-based random-dial telephone survey conducted with a representative sample of noninstitutionalized residents in California. From 2001 to 2009 the CHIS was conducted biennially, and since 2011 has been conducted annually. It is presented in various languages (e.g., English, Chinese, Korean). Our data were drawn from 2015–2016 CHIS respondents and we limited the selection to adults aged between 65 and 84 years who classified themselves as Asian American (n = 1,417) or non-Hispanic White (n = 9,170). Respondents with missing values on psychological distress (n = 110) or with a mixed ethnic background (n = 21) were excluded from the analysis.

Measures

Psychological distress was measured using the K6 scale (Kessler et al., 2002), in which the respondents are asked whether they have experienced each of six emotional states (nervous, hopeless, restless, depressed, everything an effort, and worthless) in the past 30 days. Responses are made on a 5-point Likert-type scale ranging from 0 (none of the time) to 4 (all of the time). Scores for the six questions are totaled and range from 0 = no psychological distress to 24 = the most severe psychological distress. Researchers have suggested a K6 score ≥ 5 to be an optimal lower cut-off for a diagnosis of moderate psychological distress (Prochaska, Sung, Max, Shi, & Ong, 2012). We dichotomized psychological distress into no psychological distress or having moderate/severe psychological distress based on the cut-off point of ≥ 5.

Sociodemographic factors we assessed were as follows: age (65–69 years, 70–74 years, 75–79 years, and 80–84 years), gender, marital status (married/partnered vs. unmarried), educational attainment (high school vs. college), home ownership, federal poverty level (< 200% vs. ≥ 200%), and English proficiency (limited vs. not limited). Health-related characteristics comprised self-reported health (poor/fair vs. good/very good/excellent) and presence of disability. We categorized comorbidity of asthma, diabetes, high blood pressure, and heart disease as ≥ 2 comorbid conditions versus 1 or no comorbid conditions.

Neighborhood environment assessment included perceived neighborhood safety (safe vs. unsafe), and neighborhood social cohesion, which was assessed with four items (e.g., “People in my neighborhood are willing to help each other”). Higher scores indicate stronger neighborhood cohesion. Respondents were also asked three questions regarding volunteering (e.g., volunteer work/community service) in the past 12 months and were categorized as any versus none.

Three health behaviors were included: cigarette smoking (smoked at least 100 cigarettes in their lifetime and now smoke every day/some days vs. not smoking) body mass index (BMI; kg/m²), which was categorized as normal (< 25), overweight (25–29.9), and obese (≥ 30; World Health Organization, 2000); and physical activity, which was categorized as met recommendation (≥ 150 minutes/week of walking) or did not meet recommendation (physical inactivity; U.S. Department of Health and Human Services, 2008).

Data Analysis

We utilized descriptive statistics to describe respondents' characteristics. Chi-square and t tests were used to examine differences in sociodemographics and study variables between Asian Americans and non-Hispanic Whites. To identify factors influencing psychological distress, we conducted separate univariate logistic regression analyses for each variable. We then used multivariate logistic regression analysis to assess univariately significant variables and potential risk factors identified a priori on the basis of findings of previous research (Lorant et al., 2003; Sjösten & Kivelä, 2006; Vink et al., 2008). The research model's goodness of fit was assessed using the Hosmer–Lemeshow test (Hosmer & Lemeshow, 2000). All statistical analyses were performed using SPSS 24.0. We considered p < .05 to be statistically significant. As we used publicly available secondary data, this study was exempted from Institutional Review Board approval.

Results

Respondent Characteristics

Descriptive statistics are presented in Table 1. Nearly all variables differed significantly between non-Hispanic Whites and Asian Americans, except for disability and comorbidity. Non-Hispanic Whites were more likely than were Asian Americans to have a college education, be a homeowner, have income ≥ 200% federal poverty level, perceive their neighborhood as safe, have stronger social cohesion, have good/very good/excellent health, and engage in volunteering. Asian Americans were more likely than were non-Hispanic Whites to be married/partnered and have limited English proficiency. Significant differences in health behaviors were shown: Asian Americans were more likely to have a BMI < 25, be a nonsmoker, and meet physical activity recommendations. In addition, a statistically significant difference in psychological distress was observed, such that Asian Americans were more likely than were non-Hispanic Whites to report moderate/severe psychological distress (23.4% vs. 16.7%, respectively).

Factors Affecting Psychological Distress in Univariate Analysis

We conducted separate univariate analyses for Asian Americans and non-Hispanic Whites to examine the race-/ethnic-specific association between each risk factor and psychological distress. Table 2 shows the odds ratios and 95% confidence intervals for the selected risk factors for psychological distress. The risk factors were similar between Asian Americans and non-Hispanic Whites. In both groups, the following independent risk factors were identified: female gender, unmarried status, ≤ high school education, nonhomeowner, income < 200% federal poverty level, limited English proficiency, unsafe neighborhood, lower neighborhood social cohesion, poor/fair health, ≥ two comorbidities, having a disability, not volunteering, and physical inactivity. Smoking and being obese were associated with psychological distress for non-Hispanic Whites but not for Asian Americans.

Factors Affecting Psychological Distress in Multivariate Analysis

Results of multivariate analysis are shown in Table 3. For non-Hispanic Whites, limited English proficiency was the strongest independent risk factor for psychological distress, followed by having a disability, poor/fair health, and unsafe neighborhood. Additionally, there were significant associations between psychological distress and income, female gender, and being a nonhomeowner. Non-Hispanic Whites in the older age groups were less likely than were the group aged between 65 and 69 years to experience psychological distress. For each one-unit increase in social cohesion, the odds of experiencing psychological distress decreased by 9%. Unmarried status, ≤ high school education, ≥ two comorbidities, not volunteering, body mass index, being a smoker, and physical inactivity were not significantly associated with psychological distress after multivariate adjustment. In addition, a sensitivity analysis excluding non-Hispanic Whites with limited English proficiency (n = 21) yielded very similar results to the primary multivariate analysis. The strongest factor for psychological distress was having a disability, and all other significant associations remained in the sensitivity analysis.

For Asian Americans, having a disability was the strongest risk factor for psychological distress. Additionally, poor/fair health, unsafe neighborhood, and physical inactivity factors remained statistically significant after multivariate adjustment. Similar to the findings for non-Hispanic Whites, each one-unit increase in social cohesion for Asian Americans was associated with a 12% decreased risk of psychological distress. For Asian Americans, none of the other factors were significantly associated with psychological distress after multivariate adjustment.

Discussion

In this population-based study, we found that 23.4% of Asian Americans and 16.7% of non-Hispanic White older adults in the US experienced moderate to severe psychological distress. Although limited comparative studies on the prevalence of psychological distress are available, findings suggest that older Asian Americans are vulnerable to psychological problems (Mui & Kang, 2006). Our findings indicate that, in the US, Asian Americans experience higher rates of moderate to severe psychological distress than do non-Hispanic Whites.

Our findings in this study show there are some similarities between non-Hispanic White and Asian American older adults regarding factors influencing psychological distress. Specifically, disability and poor/fair health emerged as major risk factors even after adjusting for other factors. Findings from systematic reviews support strong relationships between disability and psychological distress (Djernes, 2006; Vink et al., 2008). The association between subjective health and psychological distress has been widely documented in previous studies (Beekman, Kriegsman, Deeg, & van Tilburg, 1995; Cappeliez, Sèvre-Rousseau, Landreville, & Préville, 2004; Villeneuve et al., 2015). Taken together, these previous findings suggest strong links between physical/functional health and psychological distress in older adults in general.

Our findings, as do those in previous research (Julien, Richard, Gauvin, & Kestens, 2012), highlight the effects of neighborhood environment on psychological distress. A strong sense of neighborhood cohesion is a significant factor contributing to a lower incidence of psychological distress in many ethnic groups (Mair, Diez Roux, & Galea, 2008). Perceived neighborhood safety is also increasingly being recognized as influencing the incidence of psychological distress (Jones, Heim, Hunter, & Ellaway, 2014). Our results provide further evidence regarding the importance of neighborhood social cohesion and safety in preventing the residents from becoming psychologically distressed for both the ethnic groups we included in our analysis.

A difference we consider notable between the two ethnic groups is the relationship between physical activity and psychological distress: our results showed that physical inactivity was a risk factor for psychological distress for Asian American older adults, but not for non-Hispanic White older adults. Although findings from systematic reviews suggest that physical activity has beneficial effects on psychological outcomes among older populations (Sjösten & Kivelä, 2006), the relationship of physical activity with reduction in psychological distress is still unclear (U.S. Department of Health and Human Services, 2008). Additionally, the minimum and optimal amounts of physical activity necessary to achieve beneficial psychological effects remain uncertain (Physical Activity Guidelines Advisory Committee, 2008). Future researchers should, therefore, seek to establish this and examine the nature of the links between physical activity and psychological distress with ethnic-specific samples.

We also found differences between the two ethnic groups. For example, sociodemographics (e.g., age, gender, and poverty) were associated with psychological distress among non-Hispanic Whites, but not among the Asian Americans. Although many scholars have shown that psychological distress varies across sociodemographic variables (Lorant et al., 2003), existing empirical evidence regarding these links is controversial (Jorm, 2000). We were interested to find that limited English proficiency was associated with psychological distress among non-Hispanic Whites but not Asian Americans. These results should be interpreted with caution because very few non-Hispanic Whites (0.2%) in the sample had limited English proficiency. Among Asian Americans, limited English proficiency is common and has often been found to be related to psychological distress (Kim et al., 2011; Zhang, Hong, Takeuchi, & Mossakowski, 2012). One reason for the inconsistency could be attributable to the regional benefits of better provision of support in the state of California compared to some other U.S. states, whereby older Asian Americans in this study may have had access to formal and/or informal language support that buffered the effects of limited English proficiency on psychological distress.

Comorbidity was not associated with psychological distress in either of the ethnic groups after controlling for other confounding variables. Previous researchers have generally found an association between comorbidity and psychological problems (Marengoni et al., 2011). A possible explanation for this inconsistency could be that our comorbidity measure of a list consisting of asthma, diabetes, high blood pressure, and heart disease, may not have captured the extent to which chronic diseases are experienced in older adults. Our finding is also in line with that of Fortin et al. (2006), who found a simple count of comorbidities was not associated with psychological distress.

Strengths and Limitations

A strength of this study is that we used data drawn from a population-based survey that included a relatively large sample of older Asian Americans across California, and that was conducted in various languages. However, some limitations apply to this study. The cross-sectional research design limits our ability to make causal inferences regarding the risk factors affecting psychological distress. Another limitation is the measurement of physical activity and comorbidity. Comprehensive measures would provide a better understanding of the relationships of these factors to psychological distress. A further limitation is the aggregation of heterogeneous Asian American subgroups. Furthermore, the CHIS was conducted in California only and may not be generalizable to all older Asian American adults.

Implications for Further Research

This study has implications for research into, and clinical practice with, older adults. Increased understanding of the risk factors in older non-Hispanic White and Asian American adults is helpful in identifying persons at particularly high risk for moderate to severe psychological distress. Higher-risk groups within the given population include those with a disability and poor/fair health. Therefore, health practitioners should be aware of the increased risk of these groups for psychological distress and should screen these individuals. Neighborhood social cohesion and safety seem to have protective effects on psychological distress for community-dwelling older adults in both ethnic groups.

In keeping with our findings, intervention strategies are needed that target modification of risk and protective factors for psychological distress at the individual and neighborhood levels. Additionally, although factors associated with psychological distress were largely similar between non-Hispanic Whites and Asian Americans, there were some slight variations (e.g., physical activity and sociodemographics). More ethnic-specific research is needed to better understand these differences.

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This paper was supported by Konkuk University in 2016.

Min-So Paek, Department of Social Welfare, Konkuk University, 268 Chungwon-daero, Chungju-si, Chungcheongbuk-do 27478, Republic of Korea. Email: [email protected]