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The association between depression, chronic illness and health culture among the elderly in three ethnically distinct co...

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Title:
The association between depression, chronic illness and health culture among the elderly in three ethnically distinct communities
Physical Description:
ix, 256 leaves : ill. ; 29 cm.
Language:
English
Creator:
Lamm, Rosemarie Santora
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University of South Florida
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Tampa, Florida
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Subjects / Keywords:
Depression in old age -- Cross-cultural studies   ( lcsh )
Chronically ill -- Cross-cultural studies   ( lcsh )
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF   ( fts )

Notes

General Note:
Includes vita. Thesis (Ph. D.)--University of South Florida, 1997. Includes bibliographical references (leaves 212-235).

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University of South Florida
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University of South Florida
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All applicable rights reserved by the source institution and holding location.
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aleph - 024649155
oclc - 39175654
usfldc doi - F51-00205
usfldc handle - f51.205
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SFS0036454:00001


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THE ASSOCIATION BETWEEN DEPRESSION, CHRONIC ILLNESS AND HEALTH CULTURE AMONG THE ELDERLY IN THREE ETHNICALLY DISTINCT COM1vfUNITIES by 'ROSEMARIE SANTORA LAMM A dissertation in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Applied Anthropology University of South Florida December 1997 Major Professor : Alvin W Wolfe, Ph. D

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Graduate School University of South Florida Tampa Florida CERTIFICATE OF APPROVAL Ph D Dissertation This is to certify that the Ph D. Dissertation of ROSEMARIE SANTORA LAMM with a major in Applied Anthropology has been approved by the Examining Committee on December 1997 as satisfactory for the dissertation requirement for the Doctor of Philosophy Degree Examining Committee: Major Professor : Alvin W Wolfe Ph D Member : Roberta D Baer Ph. D Member : Vivian Ross Ed D Member : Sue V. Saxon Ph D Member : Patricia P Waterman Ph D

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Dedication To my family which includes my mother Irene who gave me the knowledge that a girl can do anything she sets her mind on doing My husband, Edwin, has always supported my endeavors and encouraged learning of what one loves My children, David, Mark, Julie and Jeffrey cheered my graduations and are waiting for this creation to applaud To my grandchi ldren, I complete this learning expenence and knowledge in dedication to the pursuit of their learnin g and enlightenment. In this way the circle will be completed This is dedicated to the memory of my dear father Anthony Santora who as an immigrant taught us unconditional l ove and understanding and the value of being authentic

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Acknowledgments During the pursuit of information for this study I was given a great deal of support from colleagues and professors Dr. Thomas A. Rich has been a constant source of encouragement since my first graduate course. Dr. Vivian Ross consistently encourages the pursuit of knowledge Dr. Alvin Wolfe supported the research and directed me in the integration of quantitative analysis which is valuable to the results of this study. The members of the Conunittee Dr. Roberta Baer, Dr. Patricia Waterman and Dr. Sue Saxon gave valuable input into the development of the dissertation and Dr. Wiley Mangum who graciously agreed to be chairperson of the Defense Conunittee Colleagues supported my studies and encouraged the pursuit of gathering research information. Dr. John Santosuosso, Dr. Sharon Masters, Mr. William Foege M .A., Dr. Bruce Darby and Dr. John Haldeman worked with me in the process of the establishment of a computer laboratory and the application of The Statistical Package for the Social Sciences I would like to also acknowledge the tireless efforts of my secretary, Karen Johnson who consistently was there

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TABLE OF CONTENTS LIST OF TABLES v LIST OF FIGURES VI ABSTRACT. Vll CHAPTER 1 INTRODUCTION 1 2 CHAPTER2 Specific Research Question LITERATURE REVIEW .. 5 Introduction . 5 Applied Anthropology and Health Culture. 6 Psychological Anthropology 9 Cultural Relativity and Diagnostic Criteria. 11 Psycholinguistics . 14 Ethnography and Case Histories. 16 Health and Kinship Systems 19 The Biocultural Basis of Health and Disease. 22 The Relationship Between Culture Mental Status and Physical Health 25 Chronic Illness and Aging . 28 Cardiac and Vascular Disease 29 Arthritis and Musculo -Sk e l etal Disease 31 Diabetes Mellitus and Aging. 3 3 Sensory Changes and Disease. 36 The Association of Chronic illness, Depression and Aging .. 39 Depression in Culturally Diverse Elderl y Populations . 49 Aging, Chronic Illness and Depression in Great Britain 56 Aging, Chronic Illness and Depression in Native American Populations 62 Summary 76

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CHAPTER3 CHAPTER4 METHODS .. 77 Introduction. 77 Groups Studied 78 Data Collection Instruments 81 The Age, Illness Depression and Ethnicity Questionnaire (AIDE).. 82 The Multidimensional Functional Assessment (OARS) 82 The Geriatric Depression Rating Scale (Short Form) 83 Bloch s Ethnic / Cultural Assessment. 85 Data Collection. 85 Participant Observation in Great Britain . 87 Data Collection in Great Britain 88 Participant Observation Among Tewa Pueblo Residents. 90 Data Collection Among Tewa Puebl o Residents . 92 Participant Observation Among the Euro Americans in Polk County Florida . 93 Data Collection Among Euro -American s in Polk County, Florida 94 Data Analysis 95 ETHNOGRAPffiC LITERATURE OF GROUPS STUDIED 96 Section I The Ethno-History and Kinship Systems of Three Selected Populations . 96 Introduction . 96 The Ethno-History of The Native American Population 97 The Tewa of San lldefonso 109 The Ethno-History of the British Population of the Midlands 11 0 The Ethno-History and Kinship System ofPolk County Residents 118 Section II The Results of Ethnographic Information . 124 Ethnographic Description and Themes of The Native American Population 125 Ethnographic Description ofNative Americans Population . 126 Interview with Respondent # 1 . 126 Interview with Respondents #2 and #3. 128 Ethnographic Description and Themes of English Persons in Lincolnshire England .. 132 Ethnographic Description ofEnglish Persons in Lincolnshire, England .. 133 Interview with Respondent #4 . 133 Interview with Respondent #5. 134 Interview with Respondent #6 . 137 ii

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CHAPTERS CHAPTER6 Ethnographic Description and Themes ofEuro-Americans in Polk County, Florida 138 Ethnographic Description of Euro-Americans in Polk County Florida . 139 Interview with Respondent #7. 139 Interview with Respondent #8 . 141 Interview with Respondent #9 . 142 The Summary of Individual s Responses to Bloch's Ethnic/Cultural Assessment and Participant Observation . 144 RESULTS OF STATISTICAL ANALYSIS OF FINDINGS . 151 Introduction . 151 Section I Summary Characteristics of Three Populations Selected for Study . 151 Age and Depression . 176 Chronic Illnesses and Depression 178 The Social Support for Respondents and Depression 181 Years of Education and Depression .. 183 Workstatus and Depression 184 Medical Costs and Depression . 185 The Number of Child r en, Grandchildren and Visits with Depression . 185 Number of Visits from Friends and the Association with Depression . 186 Gender and Depression 187 Cultu r e and Depression 188 Marital Status, Languages Spoken, Religion, Income and Depression . 189 The Guttman Technique 190 Results. 192 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS Discussion . The Association of Chronic Illness with Depression The Relationship Between Age and Depression . The Relationship Between Culture and Depression The Relationship Between Social Support Variables and Depression . The Relationship ofWorkstatus with Depression .. The Relationship Between Depression and Gender Depression and the Association with Education . Medical Costs and the Association with Depression. Depression and Its Lack of Association with the iii 195 195 196 197 198 200 201 203 205 205

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Variables ofReligion Languages and Income 206 Conclusions . 207 Recommendations 210 REFERENCES CITED 212 APPENDICES 236 APPENDIX I AGE ILLNESS, DEPRESSION, ETHN1CITY QUESTIONNAIRE 236 APPENDIX II ILLNESS LIST (OARS) 239 APPENDIX III GERIATRIC DEPRESSION RATING SCALE (SHORT FORM) . 241 APPENDIX IV BLOCH S ETHN1C/CUL TURAL ASSESSMENT GUIDE 244 APPENDIX V PATIENT CONSENT FORM.. 254 iv

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LIST OF TABLES Table 1. Population Totals, Mean Age, Mean Number oflllnesses Per Person and Number of Depressed Persons In Population 155 Table 2. Support in Household, Workstatus, Medical Cost. 164 Table 3. Marital Status.. . 164 Table4. Social Support Network. 167 Table 5 Religion Years of Education, Language Spoke. 169 Table 6 Gender and Depression. . 172 Table 7 Age Groups of Population .. 177 Table 8. Statistical Measurements of Age and Depression 178 Table9. The Statistical Measurements ofNumber of Chronic Illnesses and Depression .. . . . . . Table 10. Correlations of Selected Variables with Depression (Pearson's Rand Guttman Scalability). Table 11. Factor Analysis All Variables.. . Table 12. Factor Analysis Guttman Technique. Table 13. Chi-Square Results (n=77) Table 14 Culture and Depression Table 15. Guttman Technique, Co-efficients ofReproducibility Table 16 Guttman Technique Factor Analysis ofthe Items ofthe Geriatric Rating Scale and "De pression" . . v 179 180 182 183 187 189 190 191

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LIST OF FIGURES Figure 1. Population Totals (n = 77) . 153 Figure 2 Mean Age of Total Population (n=77) .. 156 Figure 3 Percentage of illnesses in each Population 157 Figure 4 Percentage ofDepressed Population 158 Figure 5 Depressed British Population (n = 29) 160 Figure 6 Depressed Native American Population (n=23) .. 161 Figure 7 Depressed Euro-American Population (n=25). 162 Figure 8 No. oflndividuals Respondent Resides with, Workstatus, Medical Costs . 163 Figure 9. Marital Status of Each Population 165 Figure 10. Number ofFamily Members Friends and Visits 168 Figure 11. Illnesses, Years of Education, Languages .. 170 Figure 12 Religions ofEach Population (n=77) .. 171 Figure 13. Genders of Each Population .. 173 Figure 14 Percentage of Gender Differences (n=77, n=21). 174 vi

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THE ASSOCIATION BETWEEN DEPRESSION, CHRONIC ILLNESS AND HEALTH CULTURE AMONG THE ELDERLY IN THREE ETHNICALLY DISTINCT COMMUNITIES by ROSEMARIE SANTORA LAMM An Abstract Of a dissertation in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Applied Anthropology University of South Florida December 1997 Major Professor : Alvin W Wolfe, Ph D vii

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The association between depression chronic illn esses and culture in o lder persons is st udied by comparing three populations of per so ns over fifty-five years of age from Polk County, Florida, San Ildefon so, New Mex ico and Lincolnshire England wit h respect to the variables of age presence of chronic illnesses and culture. A biographical questionnaire (Age Illnes s, Depression and Ethnicity), the Geriatric Depre ssio n Rating Scale (Short Form) a chronic illness questionnaire and Block's Ethnic / Cultural Assessment were administered to se l ected person s from each community. Cultural identity, support systems and learned behaviors were identified and measured. Other var i ables included marital status, the number of children and grandchi ldr en, the number of their v i sits, the number of visits with friends, work status, medical costs years of education languages spoken religion, income and how many persons reside with the respondent. The data were analyzed using Pearson's Chi -S quare, rank order correlation factor ana l ysis regression analysis and scalogram analysis. Analysis was also done on the etlmographic information to identify cultural themes. Significant differences in depression rates between th ese cultures were reported. The culture of indi vidua l s often direct s them in the development of beliefs that s hape their value system expressed in attitudes and behaviors related to th e aging process Culture also provides the value placed on the elderly in society which can influence feelings of hopelessness producing low self-esteem. Differences are found in attitudes toward age-related changes that might alter the development of symptoms of depres s ion in chronically ill elderly and in cultural lifeways that affect the perception of physical change in these populations viii

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Differences in depression rates were discovered between the three culture groups. The depression rate in the total population (n=77) is 28% When each population was measured separately the British (n = 29) have the most depressed population with a rate of 32% as contrasted to the Native Americans (n=23) who are the le ast depressed with a rate of 22% and the Euro-Americans rate of (n=25) 25%. The British have the highest representation among the depressed population accounting for 42% of the 21 persons categori z ed as depressed. When each population is viewed separately differences are found in the relationships between each of the variables and the dependent variable of depression Depression is a cross-cultural mood alteration and this study gives further evidence that it is a significant health problem. The Guttman Technique was used to analyze the items on the Geriatric Depression Rating Scale (Short Form) for sca lability. The results suggest a lack of universality and some items may be differentially related to depression in the several populations. These results also support the need for the development of a culturally sensitive instrument to detect the presence of depression in diverse populations. There is a need for methods to better identify the cultural context of relationsh ip s in order to prevent depression in aging persons. Abstract Approved: ______________________ Major Professor: Alvin W. Wolfe Ph.D. Professor, Department of Anthropology Date Approved: __ ________ I X

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CHAPTER 1 INTRODUCTION There is evidence of an association between depression, chronic illnesses and culture in older persons Ethnic differences have been associated with mental status changes related to physical diseases, but there is further need to better understand the relationship between ethnicity and health status In the application of clinical gerontology, individuals who are aging and presenting symptoms of depression respond to therapy and intervention in varying ways The culture of the individual has been an integral aspect of successful assessment and planning intervention for treatment. During intervention, identity of individuals is often closely associated with their culture Cultural identity, support systems and learned behaviors have been instrumental both in understanding individual problems and intervention which alleviates depression In order to better understand the association among these variables, three populations of persons over 55 years of a g e who are active and participating in activities in their communities were selected for study The variables of age, the presence of chronic illnesses and culture were evaluated in these populations representing ethnic communities with identified boundaries

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2 The cultural heritage of individuals directs them in the development of their value system The value system influences a person's attitudes and behaviors related to the aging process Culture determines, to a great extent the valu e placed on the individual in society To be considered redundant may produce low self-esteem and feelings of hopelessness These variables affect the onset of depression in aging individuals As a result older persons with depressive disorders have poor social functioning (Wells et al. 1989) Diversity in the older population presents a challenge and we must develop ways to respond to the needs of all. We are challenged to look for things that are common to all older persons regardless of race language and ethnicity while retaining things that entail specific cultural responses "Diversity will continue to be a leading force in determining the lifestyles of older people as anchors in society (Stanford 1995) Specific Research Question The purpose of this study was to clarify the association between depression, chronic illnesses and cultural differences in elderly populations The integration of theory and methods from both applied anthropology and gerontology gives this study distinctiveness and effectiveness The primary research objective identifies cultural factors related to the prevention or mitigation of depression in these special populations of older persons residing in their communities

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3 The people selected for the study represent three communities: (1) San Ildefonso Pueblo in New Mexico ; (2) Polk County F lorida ; and (3) Lincolnshire, England These populations provided subjects who reported information which is meaningful in the establishment of an association between the variables of aging chronic illnesses, depression and their culture This study provides needed insight into the issues of the integration of cultural factors depression and mental health intervention for aging individuals (Smallegan 1 9 89; Blazer 1 9 89a ; Good 1992-1993a) Another major objective of this study is to identify ethnic-cultural lifeways which may affect the perception of physical change in the elderly. I believe there are differences i n culturally constructed attitudes toward age-related changes which might alter the development of symptoms of depression in the elderly population with chronic illnesses Changes in some contemporary societies ha v e resulted in alteration of the role and status of older persons in their families and communities These changes are reflected in cultural values and practices related to the elderly Changes in culture often affect the lifeways and practices of individuals which alter self-perception often causing mood changes resulting in depression Another obje c tiv e of this study is to identify these chan g es in cultures which may be associated with depression among older individuals The cultural variables selected for analysis have been previously associated with depression in the literature The variables are : AGE : Chronological Age KINSHIP NETWORK (this category includes marital status the number of children, the number of grandchildren and those who reside with the individual and how often they visit the respondent.)

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4 FRIENDSHIP NETWORK (the number of visits from friends ) WORK STATUS (the variable includes retirement, work and avocation ) CHRONIC ILLNESSES (the type of illness the number of illnesses, and the severity of the illnesses ) MEDICAL COSTS (the expenses incurred when individuals have illnesses.) EDUCATION (years of education ) HEALTH CULTURE (the phenomena associated with the maintenance of well being and problems of sickness with which people cope in traditional ways within their own social networks ) LANGUAGES SPOKEN RELIGION (chosen affiliation) The variables selected for study are discussed in Chapter 2 Each identified variable has unique characteristics which are important to evaluate The methods in Chapter 3 identifies data collection in each selected population. This study integrates qualitative and quantititative methods Participant observation, ethnographic data, and background are presented in Chapter 4 The statistical analysis of the data is presented in Chapter 5 and conclusions and recommendations complete the study in Chapter 6 These objectives will identify the factors which contribute to the development of depression in the selected populations They will also allow for the measurement and evaluation of the variables which are observed to be relevant in understanding cultural variation These variations will be applied to the mitigation of depression in diverse cultural settings

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5 CHAPTER2 LITERATURE REVIEW Introduction The association between depression, chronic illnesses and culture is complex. The variables which are studied in this research have been identified as influencing the presence of depression in older persons Culture influences each variable and the relationship to depression Depression is a mood disorder which is experienced in somatic terms Therefore, the symptoms may be expressed in varied ways which are difficult to identify In aging populations this is further compounded by physical symptoms which distort dysphoria. Frequently the physical symptoms are diagnosed as the primary cause of complaints related to dysphoria and depression Culture often significantly influences the expenence and communication of symptoms of depression (Manson and Guarnaccia 1997) The culture also influences the diagnostic criteria which identifies depression dysphoria, and major depression Cultural relativity in relationship to diagnostic criteria is presented in this chapter.

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6 The expression of feelings are influenced by the cultural relativity of the expenence This experience is also expressed with communication This process is further influenced by the language of a culture Psycholinguistics is discussed in order to better understand these influences Chronic illness in the aging population has a strong association with the presence of depression in the elderly It is essential to understand the relationship between these illnesses the biocultural basis of health and disease and the ways of acceptance across cultures Health culture is a major phenomenon which will further be discussed in this chapter. The culture of aging individuals often affects how an individual experiences and expresses the feelings of "sadness, loss, and change", but also the mitigation of the symptoms These differences are presented in order to better understand the influences of the selected variables in each of the culturally diverse elderly populations selected for study Applied Anthropology and Health Culture The definition of culture is both simple and complex The evolutionary perspective of culture best describes it for the purpose of this research

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7 Culture is the human made environment, encompassing the physical space in which humans are located, the behavioral patterns that contribute to their utilization of and interaction with the natural environment the intang i ble outgrowths of such behavioral patterns, and the tangible products used to further modify or interact with the environment" (Moore et al. 1987 : 5) Evolution is another unifying theme which can be used in Anthropology to integrate the biological and the cultural aspects of a society Evolution explains the biological characteristics which survive in individuals explaining the epidemiological differences in health between cultures Medical anthropology integrates culture and evolution, time and space and biological variability utilizing methods of comparative and holistic analysis (Moore et al. 1987 : 6-8) The Western Medical Model was built on the etic view of health. The basic dualities of modem Western medicine are the concepts of: (1) Science and magic; (2) Individual and population ; (3) The body and the mind ; and ( 4) Technological and anthropological (holistic) treatment (Wolinsky 1992 : 6 7) Cartesian philosophy proposed that the mind should be given unto the care of God, while the body and physical functioning was the arena for medicine to study This rationalist philosophical view reinforced the Roman Catholic position that he mind-body dichotomy existed (Wolinsky 1992 : 7-8). Advances in medicine occurred during the Industrial Revolution and humanitarianism promoted sanitary conditions which improved the living conditions of individuals

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8 Scientific knowledge produced the germ theory of disease creating the basis for etiology of disease and an understanding of the epidemiological factors related to the disease process (Wolinsky 1992 : 5-6) The major theoretical problem with the Western medical model is the specific mechanistic, casual explanation used to understand disease (Moore et al 1987 : 10) This scientific process of etiological cause and effect has established a rigid treatment oriented system of health care. The treatment and intervention plan is based on identification of the organism and a diagnostic regime which results in the treatment of choice Rarely is there a multi-focal approach in the diagnostic process In contrast etiological processes in other cultures often include social or supernatural and natural causes of disease (Cassidy 1992 ; Joseph and Shweder 1 9 92 : Illingworth 1 9 92) Health and disease are phenomena that are constantly changing The variation is a result of a society s interpretation of health and disease changes in biological and cultural factors, and through biological and cultural adaptations conferring health (Moore et al 1 9 87 : 12) Ifwe are to accept the role of society and culture affecting health status we must also identify what culture is. Helman ( 1990) defines culture as a set of guidelines both explicit and implicit, which tells them how to view the world, how to experience it emotionally and how to behave in it in relation to other people to supernatural forces, and to the natural environment" (Helman 1990 : 2-5) Applying this description culture has an important influence on many aspects of peoples lives including illness pain health, and health care.

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9 Logan and Hunt (1978) state that "medical anthropology has been defined as "a bio-cultural discipline concerned with both the biological and sociocultural aspects of human behaviors and particularly with the ways in which the two interact and have interacted throughout human history" (Logan and Hunt 1978 : 2-3) Psychological Anthropology Hollowell (1967) described Ethnopsychology as the field that integrates anthropology and psychology He reported that self-awareness was largely excluded from theorizing about the basic constituents of culture He noted that pan-cultural constructs did not include elements of experience of the self (in Schwartz, White, Lutz 1994 :21 ) Interest in Ethnopsychology has increased in recent years and the integration of folk awareness in assessment and treatment in mental health is beginning to occur. Ethnopsychology has been defined by Shweder as the concern for the investigation of mind, self, body and emotion as topics in ethnographic studies of folk beliefs" (1990 : 16) The study of Ethnopsychology has produced a greater awareness of the culture-bound quality of categories and models that are the basis for the development of theories These theories of personality may often skew the results toward models that are similar to Western conceptions of the individual (White 1994 : 22-23)

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10 The integration of culture and psychology includes the study of person and self Geertz ( 1973) argues that this necessitated searching out and analyzing symbolic forms such as words, images, institutions, and behaviors where people represented themselves to themselves and to one another In a study by Baer (1992 : 3), two important questions about the measurement of mental status of a Mexican-American minority population were raised The first was how the domain of health and mental health is categorized by this population and the second how this population perceives and understands standard questions used to measure prevalence of major mental illnesses These questions were primarily an attempt to understand the perceptions of this minority population and how they differed from those of the biomedical community (Baer 1992 : 3) The perceptions of individuals in cultures which have integrated systems and folkways with medical practices reflect an ernie perspective This ernie perspective is frequently ignored by investigators A major issue in evaluation of mental health status is the population's perception of mental health Baer (1992:6) differentiates between categories of mental status changes which are labeled by the Mexican-American culture Theses changes are recognized as folk illnesses which the Western medical model has not incorporated into the diagnostic nomenclature of bio-medicine Spiro presents a dichotomy which is "culture is a public system, thoughts are no less than emotion are, by definition, excluded from 'culture"' (in Schwartz, White and Lutz 1994 : 181) Ewing (1994) argues that participant observation is an arena where psychoanalytic observations may be of value (in Schwartz White and Lutz 1994 : 181 )

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11 She also supports Geertz s integration of self and culture when he defined his goal as understanding natives' inner liv es" ( 1973 : 57) Furthermore Geertz' s process of equating symbols culture, the public arena, and communication has become a central paradigm in anthropology (1973 :55-70) Good (1994 : 181-201) discusses the current trend in mental health which supports biological and genetic research but does not fund research in the cross-cultural study of psychopathology Anthropologists have made many contributions to the theories related to human development mental illness, and understanding the etic view of non-dominant cultures Anthropologists have often ridiculed psychiatric diagnostic categories rather than suggest research which integrates these categories with structures from the paradigms of cultural anthropology (Good 1994) Henry Stack Sullivan and Edward Sapir are credited with developing a research agenda which included cross-ethnic and cross-cultural studies of normal personality and then moved on to studies of psychopathology (Darnell 1986 : 156-183) This process provided a baseline knowledge of behavior which might offer understanding related to maladjustment in all cultures. This approach to understanding psychological deviation and behavioral alteration is culturally relevant. Cultural Relativity and Diagnostic Criteria The categorization of vanous psychopathologies and conditions has been integrated into culturally rele v ant diagnostic classifications

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12 The psychiatric nosology which developed in the recent thirty years has a focus on the "quantitative techniques to improve reliability and investigate validity of diagnostic criteria" (Good 1994 : 183 ) This approach IS labeled the Neo-Kraepelian conceptualization of psychopathology The classification of the behaviors is based on descriptions and criteria which were modeled from the system developed by the nineteenth century German psychiatrist, Emil Kraepelian (Good 1994 : 184) Researchers led by Samuel Guze, Eli Robins, George Winokur Don Klein, and Robert Spizer developed the new approach to psychiatric diagnosis (Good 1994: 184) This process of identification and classification of psychiatric phenomena is named the Feighner Criteria which provided the structure for the revision of the American Psychiatric Association s Diagnostic and Statistical Manuel Disorders Ill (1980a 3rd Edition) The Diagnostic and Statistical Manual of Mental Disorders-Ill (1980a 3rd Edition) has moved beyond the conceptual boundaries of traditional medical philosophy of diagnosis by assessing phenomena in order to label and incorporate it with cultural data This is a code of diagnostic assessment with a constellation of various types of data that bear upon the psychiatric episode This process incorporates more conceptual "tools" for construction of more adequate models of observed phenomena (Hughes, Blazer and George 1985 : 13 ) This approach allows the clinician to integrate a diagnosis from Axis I and Axis II which includes mental disorders with psycho-social stressors from Axis IV of the DSM-III as part of the diagnostic criteria In this process the culture-bound" syndrome may be more easily integrated (Hughes Blazer and George 1985: 17)

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13 The culture-bound syndrome is described by Hughes and associates ( 1985 : 21) as the culture of the person who is being evaluated with enough detail to make a valid behavioral assessment. The challenge of identifying accurate criteria is recognizing the values and meanings of one's own culture and class and how it impacts assessment. The theoretical basis of the culture-bound syndrome is presenting a challenge to the use of the Diagnostic and Statistical Manual and transcending cultural parochialism (Hughes, Blazer and George 1985 : 21) A paradigm shift in psychiatry occurred as a result of political and social factors These factors included deinstitutionalization of the mentally ill and the development of community mental health centers (Haber et al. 1982 : 22-23) The community mental health centers were mandated to provide services under the Community Mental Health Centers Act ( 1963) which included a holistic integration of social psychological evaluation and treatment. This service provision enhanced the integration of anthropology and psychology in assessment and treatment intervention A major problem with integration of anthropological theory and practice in the field of mental health was the willingness of State or Federal governments to adequately fund or otherwise arrange for community mental health Therefore the concept of the individual s culture being integrated into the diagnostic and treatment plans was a goal which was not attained The emphasis on the quantitative measurement and outcome of diagnostic criteria evaluation became the hallmark of mental health program survival

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14 The Diagnostic and Statistical Manual (1994c:IV) integrates the epidemiological research which identifies characteristics that make individuals vulnerable to diseases with triggering events which may lead to the onset of a disorder. These factors are integrated with neurobiology and pharmacology which result in the paradigmatic shift from an etic epidemiolo g ical concept to a one which is Western Ethnopsychological (Good 1994 : 186) The deficit in the application is the lack of re s earch education and training related to culturally relevant evaluation, treatment and intervention (Manson and Guarnaccia 1997) Psycho linguistics is important in order to better understand the ernie view of individuals Psycholinguistics P sy ch o linguistic s i s important in o r der to better understand the erruc view of individuals Communication is a maJOr element of psychological evaluation and intervention Psycholinguistics is defined as the study of communication and the charac t eristics of the p e rson communicatin g" (Brennan 1 982: 3 2 9 ) Psycholingui s tic theory proposes that the major function of language is the con v ersion of id e as conceptions, and thoughts into sentence structures which allow culturally relevant information to be transmitted for e v aluation Brennan (1982 : 3 2 9) asserts that langua g e is also basic to understanding problem-solving behavior self-perception, and social relationships Psycholinguistics is also the study of the meaning of words or the semantics of those words and sent e nces

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15 The biological and cultural determinants of language development have provided the theoretical basis of interdisciplinary research in the behavioral sciences anthropology, sociology, computer science and philosophy (Brennan 1982 : 329) Language provides a means of investigating social phenomena and is an imp9rtant aspect of ethnographic research (Bauman and Adair 1992:23). Often, language is an excluded element in the development of research tools used to collect data in assessment of mental health problems Difficulties of communication are inherent in collecting ethnographic information from minority populations Illingworth (1992 : 1-6) discusses the words used to describe symptoms of mental status and behavioral change in an African-American community and she notes the many problems associated with persons who did not understand meanings of words in the questions Frequently, researchers reflect a value laden approach and respondents do not verbalize information which is understandable to them In order to circumvent these problems participant observation is a valuable tool for anthropologists to use when collecting cultural knowledge (Illingworth 1992 : 24) Knowledge of the meaning of words in the language is also a valuable tool to accurately collect information Many instruments which have been developed to collect information related to health and mental health have not integrated the meanings of words which reflect health culture variations The major methodological problem with using psychological tests is that they tend to be culture-bound (Edgeton-Langness 1974:47-48)

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16 Standardized testing and data collection for purposes of comparing cultures is often not valid Therefore, the anthropologist must gather useful information from listening to and participating in conversations with members of the community which is studied (Edgeton and Langness 1974 : 42). The depth of interviews of the life history forms of interviewing are valuable in data collection These interviews may result in collection of relevant psychological information The interplay between the individual and the culture may also be observed in the process of data collection (Edgeton and Langness 1974 : 38) Ethnography and Case Histories Health surveys and questionnaires are a process of communication The collection of this type of information is complex and must recognize vast variation among individuals (Joseph and Shweder 1992 : 36-38) This process must include the variables related to the ethnicity, culture and socioeconomics of the subjects (Bloch 1983) Techniques of traditional participant-observation and ethnographic inquiry are necessary in order to obtain data with cultural information relevant to health status (Edgeton and Langness 1974 : 47). The Biomedical Model is inadequate as a practical guide to clinical care because it does not conceptualize common interpretive conflicts in communication Resolution of these problems requires a framework that allows the investigator to place various cognit i ve systems side by side This juxtaposition permits comparative study of a variety of systems of medical beliefs and common sense (Kleinman 1980 : 103-1 07).

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17 The semantic sickness network includes these systems in relationship to the Explanatory Model of illness (Kleinman 1980 : 1 08). Semantic sickness network is based on large cultural categories called semantic domains such as animals, plants emotions, body parts, illness and disease (Casson 1994 : 69). Helman (1990 : 103) presents four categories that constitute the theoretical basis of illness causation He sees them as existing around the patient, with the patient centered within his social, natural, and supernatural world Christman ( 1977) described eight etiologies of illness which are more commonly accepted in the Western industrialized world These include (1) debilitation; (2) degeneration; (3) invasion ; (4) imbalance ; (5) stress ; ( 6) mechanical causes; (7) environmental irritants; (8) hereditary proneness These theoretical bases for illness causation are often the constructs for hypotheses development in health research (in Helman 1990 : 1 03) The variables related to etiologies must be integrated into the methods of data collection in order to devel op intervention plans and are more accurate when they incorporated into models of health Joseph and Shweder (1992 : 16-26) presented fifteen models of health which are vital to incorporate into health questionnaires These models are : (1) homeostasis; (2) energy ; (3) absence of pain or disease ; (4) fitness; (5) weight ; (6) diet or food ; (7) activities of daily living; (8) genetic stock ; (9) immunological resistance; (10) subjective impressions-how one feels ; (11) autonomy; (12) interaction with social institutions; (13) control of emotions; (14) moral development ; and (15) soul or sm s icknes s (Joseph and Shweder 1992 : 116-1 26)

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18 The Culture / Cognitive Models "are presupposed, taken-for-granted models of the world that are widely shared by members of a society and that play an enormous role in their understanding of that world and their behavior in it. Cultural models are mental and behavioral representations of a particular domain that are composed of and reflect the conceptual worlds which people inhabit" (Joseph and Shweder 1992 :9 ) This description indicates that culture influences the talk and behavior of individuals which affects their perception of health and emotions The application of this complex process is a great problem in mental health research, treatment and intervention Ethnicity is an important variable in health and illness. Issues such as patterns of utilization, health care planning, and morbidity profiles are affected by the ethnicity of the population to be served Incorporation of the variables of ethnic group identity reflects a different theoretical framework which prevails within the structure of modem scientific medicine (Weidman 1978 : 9) Weidman (1978:9-13) rejects the assumptions that individuals' beliefs and behaviors will be abandoned in favor of orthodox new ones This led to development of the inclusion of Health Culture into conceptual and methodological process in the Health Ecology Project. This project integrated both traditional and orthodox health culture systems (Weidman 1978 : 15). Chambers ( 1989) indicates that one of the most important contributions of anthropology is the use of in-depth site specific understanding of cultural phenomena provided by ethnographic methodology Methods of cross-cultural comparison are complex and the researcher must narrow his/her focus to the problem

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19 The most important aspect of the method is the creation of a good question, one whose answer provides information relevant to more general theories about persons and their culture (Edgeton and Langness 1974 : 95) The information collected must be accurate, complete and the theory that underlies the research must allow facts to be associated which leads to better understanding ofthe individual (Edgeton and Langness 1974 : 93) The application of this complex process is a great problem in mental health research, treatment, and intervention The ethnographic literature pertinent to the three populations compared in this study is presented in Chapter 4 entitled Ethnographic Information Health and Kinship Systems Kinship is a universal element of every human group with varying patterns. The family has been identified by anthropologists and social scientists as a vital productive element of society (Segalen 1988:74-75) From an anthropological perspective, the relevance of the concepts related to the family is rooted in the historical observations that the family and kin ties provide the links to the society Mogey (1956) rejects Parsons view that families in modem industrialized societies are cut off from their kinship network when he presented the concept that social isolation of the family from the kinship group has not occurred Furthermore these contacts with the kinship group often provide support, advice, material help and financial assistance

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20 A modem belief is that the elderly are cut off from their families and kinship ties Research indicates that most persons who are elderly, live near at least one family member, having at least one weekly contact (Brown 1990 : 128) The importance of recognizing family and kin is the role they play in support of the aging individual in society that requires independence for survival needs Physical, psychological and social changes in the aging individual require more dependence on the social system, therefore the family is often the structure which is most depended on An important change in the modem industrialized society is the diminished role the aging individual has in the family. This dependence associated with role constriction has created a vacuum for the elderly which leads to individuals being isolated and depressed (Brown 1990 : 128-129) Families are generally regarded as domestic groups within which reproduction takes place Gellner (1957) defines kinship structure as the connection between the etic categories of biological relatedness and the ernie categories of kinship terminology that constitutes kinship"'. This concept is important to establish because the roles and relationships of the populations studied are cultural and social v ariations of clans and lineages The biological link is between children and the woman while the association between man and woman is social There has been a biological basis for the development of the family Kinship still performs important functions in our post-industrial societies (Segalen 1988:43-44) Families and kinship groups have provided a natural organization which can facilitate economics, production child-rearing, politics, education, and law. When these basic needs are met individuals can also find safety and comfort within these units

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21 Mead (1956 : 26-35) related that upon her return trip to Peri 25 years after her first visit even with cultural change the roles of the members of the society had not changed significantly. Her discourse relayed the importance of the structure of the domestic group and the organization governing the transmission of practices, cultural values, and family interaction (Segalen 1988 : 22) Mead (1956) suggested that when we look at different civilizations and observe vastly different styles of life to which the individual has been made to conform to the development of which he has been made to conform, to the development of which he has been made to contribute, we take hope for humanity and its potentialities" ( 1956 : 153 ) She further noted that these potentialities are passive not active, helpless without a cultural milieu in which to grow" (Mead 1956 : 153) The rites of passage of transition of old age vary among cultures Norms are important variables for anthropologists and social scientists to evaluate when studying individuals as members of groups and societies Bott (1957 : 193) defines a norm as a typical pattern a generalized model of conduct which reflects their stated ideals and expectations Urban families are thought to have more freedom to govern their own affairs, whereas small-scale societies have more control of the family (Bott 1957: 100103) Erik Erikson (1959) criticized Murdock and Whiting's anthropological research because it was extremely uneven and unsystematic and rarely distinguished among observed behavior, ideal patterns and projects of the investigator's stereotypes" (in Lewis 1970: 105-1 06)

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22 Lewis (1970 : 87) indicates the intensive study of representative families can give us the range of custom and behavior which can serve as a more adequate basis from which we can derive culture patterns The intimate knowledge of cultural rites of passage is a valuable tool in assessing a society's attitudes on aging The Biocultural Basis of Health and Disease In the complex process of integration of cultural variables and mental health the importance of the physical health of individuals is vital in the process of diagnosis, intervention, and treatment of depression Illness is the variable most often associated with the onset of depressive symptoms. Moore and her associates (1987: 97 -98) suggest that culture and community have a great influence over health and the influence persists throughout life. The relationships between biological, behavioral and social processes and the synthesis of environmental and community relationships are complex but they are vital in the understanding of individuals living in harmony w i th their environment. Development of the individual in the Human Ecosystem Model establishes interaction among body organ systems and behavioral elements (Moore et al. 1987 : 92). The factors in this model include environmental variables and human made sociocultural factors These factors represent a holistic view of an individual s adaptive capacity in the health-sickness process" (Moore et al. 1987 : 15).

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23 Ekistic development is part of the Human Life-Span Model developed by Aldrich (Moore 1987 : 94-96) This term refers to "the process by which one's habitat, or human settlement impacts on other processes critical transition periods and life events" (Moore 1987 : 95) This theoretical model is the basis for the understanding influences of the v ariables of age, chronic illnesses, and culture on the development of depression in individuals Human development involves many factors and variables in a continuum throughout the life cycle Erikson (1959) included Adulthood and Mature Age in his categories of human development. Adulthood includes Generativity versus SelfAbsorption in which he indicated that psycho-social crisis occurred which included s ignificant relations elements of social order, psycho-social modalities, and psycho sexual s tages (Erikson 1959) These stages of development indicate that growth and change occur until the death of an individual These stages include the variables of (1) education; ( 2 ) labor ; (3) tradition ; (4) wisdom ; (5) being; (6) significant relations; and (7) non-being Cultures vary as to how they recognize development during phases of the life cycle (Moore eta!. 1987 : 137) Kohlberg ( 1973) sees growth in wisdom and moral development as a possibility which does not always occur with age The social ages are marked by the attainment of universal ethical principle and respect for human dignity The concept of the rite of passage allows us to better understand change in age status Age is a quantitative measure of time it is also a position and status in society

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24 Transitional periods often help in the development of individual autonomy Each phase of the life cycle, although different is linked to past and future phases of development (Van Gennep 1960 : 191; Moore et al. 198 7 : 13 7-13 8) The rites of passage are a link between individual development and cultural variation in human adaptation Biocultural change is an adaptive process for human beings In middle age physical growth diminishes and the organism begins to lose functional capacity in organ systems This physical change brings about psychological and social change which affects the lifeways of individuals Culture impacts developments which occur during the aging process (Moore et al. 1987 : 156-157; Neugarten and Moore 1972:93-95) Physical change in the aging process is a cross cultural phenomenon. Saxon and Etten (1978:9) proposed that aging should be viewed in developmental perspective and as a natural part of the life cycle Biological developments during middle age may predispose individuals to the disease in later life. Aging and the disease process must then be studied in a multi-dimensional process which integrates the physical change with psycho-social adaptation and the environmental conditions present in the milieu of the individual. The cellular demise of the body reduces the functional capacity of the individual while the energy level is also deminished When the organ functions are compromised in human physiology, the end result is a response which causes an alteration of homeostasis. This alteration is viewed as disease and categorized as illness. Since aging is continual biological and behavioral change physiological alteration is a universal cross cultural phenomena. Culture is an important part of the variation through its effects on the environment, life-style and attitudes of individuals (Moore et al. 1987: 180).

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25 The Relationship Between Culture, Mental Status and Physical Health In the complex process of the integration of cultural variables and mental health, the importance of the physical health of individuals is vital in the process of diagnosis, intervention, and treatment of depression. lilness is the variable most often associated with the onset of depressive symptoms. Chronic illnesses are far more prevalent in the elderly population than among younger persons Eighty percent of all persons 65 years and older are reported to have one or more chronic illness (Report of the Surgeon General 1990). Even though chronic illness is not age specific, the elderly have activity limitations, physical handicaps and mental disabilities associated with long-term illnesses There is thought to be a definite association between depression in the elderly and the presence of chronic illness (Blazer 1989:69). Anita L. Stewart and her colleagues (1989) reported finding significant mental health differences between patients without chronic conditions and those with any five chronic conditions. They suggested further research to ascertain the level of mental health functioning of patients with chronic medical conditions. Kenneth B. Wells and researchers (1989) reported unique associations between specific chronic medical conditions and depressive symptoms They also indicated that functioning and well-being were associated with symptoms of depression in chronically ill persons The association of these variables indicate that appropriate assessment and treatment could reduce morbidity in older persons and improve functioning

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26 Maser and Dinges ( 1993) reported the need to further understand the comorbidity factors (multi-diagnosis) in cross-cultural clinical research. The research conducted by the National Institute of Mental Health (NIMH) and the Indian Health Service actively sought to (1) enhance awareness of comorbidity issues; and (2) to learn if there are special issues of psychopathology and comorbidity that affect American Indian and Alaska Native populations (Maser and Dinges 1993 :409-425) The Diagnostic and Statistical Manual 111-R (1987) has not paid attention to these cross-cultural diagnostic issues The International Classification of Diseases does not provide diagnostic criteria which includes the reality of cultural influences (1977 ICD-10 World Health Organization) As a result of the absence of cultural nomenclature the accuracy of physical and mental diagnosis is reduced (Manson and Guarnaccia 1996) As previously indicated culturally specific disorders are not included in the nomenclature of the DMS-IV (1994c) and the ICD-10 (1977). Kleinman and Good (1985) indicate that cross-cultural research makes clear that the phenomenology of disorders and the "meaningful forms through which distress is articulated and constituted as social reality, varies in quite significant ways across cultures (Maser and Dinges 1993:298) Physical illness and the prevalence of depression in the elderly American Indian and Alaska Native are very high (Baronet al 1988 : 217) Depression alcoholism, and suicide are the most prevalent psychiatric diseases in this population. Studies have indicated that mood states including depression are related to social pressures on native life, cultural changes and tribal definitions of self

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27 American Indians are treated for depression more than any other ps y chiatric disorder, representing 40 percent of all visits to mental health facilities This disorder manifests between these disorders is poorly measured diagnosed, and treated (Manson et al 1985) Native Americans integrate traditional hea l ing practices with contemporary mental health intervention Traditional methods include : (1) the four circles ; (2) the talking circles ; and (3) the sweat lodge T he four circles integrate significant relationships in one s life The therapeutic e ndeavor is the search for balance and harmony which also includes the Creator. The talking circle is a form of group therapy in which the ritual connects the individual, physically and psychologically with the Creator (Kleinman and Good 1985:3 3 1-33 3 ) The sweat lodge ceremony is divided into rounds and the seat ph y sically clean s es the partic i pants and induces a sense of both energy and serenity The ritual purpose is to bring the participant closer to the Creator. The Indian Health Service has incorporated the sweat lodge and other trad i t i onal healing practices into alcoholism and mental health treatment programs (Manson, Walker and Kivlahan 1987 : 165) This example of the integration of psychological factors and phys i cal change and illness is an essential aspect of the assessment and successfu l treatment of the elderly. The elements ofthe assessment include : (1) predispos i ng factors ; (2) familial patterns ; and (3) the course of illness (Mas e r and D i nge s 1993 :416 ) When this data is collected it must be evaluated by a clinician who is familiar w i th the culture of the patients and analyzed with a complete history of the individual This integration of psycho-bio-cultural information aids in the formulation of a mor e su i table intervention and treatment plan

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28 Maser and Dinges ( 1993: 419) propose that there are cultural differences which can be found if symptoms are identified which could provide diagnostic criteria for a crosscultural clinical manual. The integration ofFabrega s (1987 : 383-394) theory of illness / self conceptualization could provide the holistic approach to diagnostic criteria development which is necessary for the integration of cultural factors, physical status and behavioral symptoms Chronic Illness and Aging As has been previously identified, the presence of illness is more prevalent in the aging population The reduction of functional capacity associated with biological aging presents a threat to the individual (Kart Metress, and Metress 1992 : 32-33). Kane, Ouslander and Abrass (1989 : 5-6) report research on aging which indicates cellular loss over time diminishes organ function which is necessary for adaptation to the environment. This diminishing function is observed when the individual begins having difficulty in coping with the environment and this often is labeled a disease process As previously noted, the health status of an i ndividual is integrated with his/her physical mental and social well being (Kart Metress and Metress 1992 : 32) This multidimensional assessment is also integrated with the health culture of the individual The Health Culture "refers to all phenomena associated with the maintenance of wellbeing and problems of sickness with which people cope in traditional ways within their own social networks and institutional structures

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29 It is a general term which includes both the cognitive and social system aspects of health traditions (Weidman 1978 : 13) The concept of health is reflected in three subcategories : (1) general physical health and the absences of illness; (2) the ability to perform basic self-care activities (activities of daily living) ; and (3) the ability to perform more complex self-care activities (Kart, Metress and Metress 1992 : 32). The elderly are more likely to ha v e a serious illness which predisposes them to chronic physical psychological, and social change which reduces their ability to perform activities of daily living (U.S Bureau of Census 1990b ) The most commonly treated diseases in elderly populations as reported are : coronary heart and vascular disease; lung disease including chronic obstructive pulmonary disease; visual problems with lens surgery; gastrointestinal diseases ; nutritional diseases ; genito-urinary problems; and musculoskeletal diseases (Vital and Health Statistics of the United States 1986) Treatments for acute onset illnesses were administered in hospitals but were related to long-term presence of functional change in the body systems. Cardiac and Vascular Disease Cardio-vascular changes and disease are the most prevalent alteration of physical homeostasis in populations in the industrialized world (Fry and Hasler 1986:66-69) This disease process produces: (1) hypertension; (2) stroke ; (3) arteriosclerosis; ( 4) atherosclerosis; (5) kidney and liver disease ; (6) dementia ; and (7) cardiac failure

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30 It is the most debilitating chronic illness of the elderly population (Fry and Hasler 1986 : 66-69) Recent research indicates that moderate physical exercise reduces death from ischemic heart disease and increases life expectanc y in persons over 80 years of age (Lindsted, Tonstad and Kuzma 1992 : 34-35) The success of prevention health programs in the industrialized world has reduced the mortality rates from ischemic heart disease in men between 35 and 77 years of age (Fry and Hasler 1986 : 66 67 ). The Royal College of General Practitioners indicated that one-half of all strokes and one-fourth of deaths from heart disease in people und e r 70 years of a g e were preventable with the application of existing knowledge (in Fry and Hasler 1986:70) This supposition is validated by the demographics which indicate that changing health habits may contribute to reduction of heart disease in younger populations (Fry and Hasler 1986 : 67) These changes in health behavior do not inhibit age related functional changes in the Cardio-vascular system Oxygen consumption is one of the most vital functions of the body. The ability of the organism to transport oxygen from the atmosphere to the body organs is a major physiological interaction of living This function is called Vo 2 max and it declines at 1 percent per year during the aging process Cardiac output declines with age and is the result of decreased stroke volume (Lakatta 1979) Systolic blood pressure increases with age and total peripheral resistance also increases Left ventricular function decreases with inactivity and increases with exercise (Lakatta 1979)

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31 Decline in cardiac output and increased peripheral vascular resistance cause cardiac disease and hypertension The amount of fatty tissue in the heart increases and heart valves become more rigid and thick. The arteries and veins also become less elastic which causes arteriosclerosis and atherosclerosis These diseases cause hypertension and other cardiac changes (Saxon and Etten 1994b : 80-83) Cardiac changes produce diseases that compromise the body functions and reduce the individual s ability to carry on self-care These functions constrict the lifestyle of aging individuals which causes dependence This alteration in lifestyle produces changes in the psychological and social status of elderly indiv i duals Arthritis and Musculo-Skeletal Disease Osteoarthritis is the most common joint disease in persons over the age of 50 The joint capsule becomes thickened which restricts movement causing instability and deformity (Kart, Metress and Metress 1992 : 89-90) Degeneration also occurs which is primary idiopathic Osteoarthritis Weight-bearing joints are also affected by the disease (Brandt and Fife 1983) Kart (1992 : 91) reported that eighty-five percent of individuals over age seventyfive demonstrated radiographic evidence of Osteoarthritis In general individuals with Osteoarthritis have pain from the inflammatory musculoskeletal condition Immobility is the result of the changes in the musculoskeletal system of aging individuals

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32 Immobility is the "the common pathway by which a host of disease and problems in the elderly produce further disability (Kane, Ouslander and Abrass 1989 : 213-224) The treatment of choice for Osteoarthritis is non steroidal anti-flammatory drugs which cause side effects (Kane, Ouslander and Abrass 1989 : 224) These side effects produce gastrointestinal upset and bleeding, dizziness, confusion, somnolence, sodium retention, and analgesic effects (Kane Ouslander and Ab r ass 1989 : 224 Table 8-9) This iatrogenesis coupled with immobility results in severe physical complications which restrict activities of daily living and are common manifestations of depression (Kane Ouslander and Abrass 1989 : 215) The effects of arthritis on individuals' physical emotional and social well-being have been well established in medical research Meenan and his associates (1980) developed a multidimensional index that measures the health s tatus of individuals with arthritis The Arthritis Impact Measurement Scales (AIMS) is a health status measurement which assesses: (1) mobility ; (2) physical activity ; (3) dexterity ; (4) social role ; (5) social activity; (6) activities of daily living; (7) pain ; (8) anxiety; and (9) depression (1980:146-153) The assessment research indicates that each indicator score increases with decreasing health status on the Guttman Scale (Meenan, Gertman and Mason 1980 : 146-153) Depression was highly correlated on the scale at CR 0.90 Alpha 0 84 (Meenan, Gertman and Mason 1980:151). Depression was also strongly related to the subjects perception oftheir mental status (Meenan Gertman and Mason 1980 : 151)

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33 Osteoporosis is a common disorder in the elderly population and it is a major cause of pain disability, and immobility This disease process is a generalized bone disorder with diminished bone mass Type I osteoporosis occurs in postmenopausal women while Type 11 occurs as a result of impaired production of Vitamin D in the very old population (Kane, Ouslander and Abrass 1989 : 225) Osteoporosis is an underlying asymptomatic process which causes fractures of the hip and vertebrae, kyphosis and loss of height The results of this immobility are frequently acute surgical intervention, prolonged pain, and organ system failure This immobility also is the underlying dynamic which often threatens mental and social wellbeing (Kane, Ouslander and Abrass 1989 :22 8-241 ) Muscle disuse is often the result of musculoskeletal disease Disuse and muscle dysfunction produce a decrease in aerobic muscle metabolism ( Rothchild 1986 : 94) This disuse and reduction of oxygen to the muscle mass results in weakness and diminished strength When elderly individuals have musculoskeletal disease they are often in a circular pattern of reduced stimulation which creates inability of action resulting in disuse atrophy Disuse atrophy causes immobility which restricts activity and results in isolation causing symptoms of depression Diabetes Mellitus and Aging The elderl y are more susceptib le to the onset of diabetes Eight percent of persons in the United States \VllO are 65 years of age and older have diabetes

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34 This is three times greater than the rate in the general population, and forty percent of all diabetics are over age 65 (Campbell1987 : 10). Treatment and intervention for diabetes in the elderly includes : (1) normalization ofblood glucose; (2) diet alteration; (3) exercise regime; and (4) education. The problems associated with complacence are the physical changes that reduce the ability to exercise and the lifeways which inhibit dietary change and acceptance of medical intervention and education (Campbell 1987 : 1 0) Diabetes Mellitus and sustained hyperglycemia cause accelerated agmg with thickening of capillary basement membranes, abnormal collagen formation, decreased fibroblast replication, and abnormal lipid metabolism. These cellular changes cause the physical complications in the organ systems Heart attacks, strokes, peripheral vascular disease, retinopathy and blindness, neuropathy, hearing and vision loss and memory loss are chronic changes resulting from diabetes (Campbell1987 : 10-11) Treatment of diabetes in the elderly alleviates the onset of organ change in body systems Diet restriction, self -monit oring of blood glucose, exercise regimes, caloric restriction, and oral medications are often confusing and alien to elderly persons These changes in lifeways conflict with le arned behaviors which have been culturally reinforced The Zuni Diabetes Project is an example of a community-based program for Native Americans who have one of the highest rates of diabetes in a population in the United States (Patton 1986:37-38) The Pima Indians have the highest at risk rate for diabetes with fifty percent of adults over the age of35 in a population of 10,000 (Patton 1986 : 38)

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35 In the Zuni population there is a risk of one out of three persons developing the disease (Patton 1986 : 36). The Zuni Diabetes Project promoted the change in lifeways which included a return to exercise and altered dietary patterns The sedentary activity patterns and high caloric food intake were changes in lifeways for the Zunis Running had been a traditional physical activity integrated with the religious heritage of the sacred footrace (Patton 1986:37) Tribal members often ran for thirty miles or more and were very involved in hunting and agriculture Their lifew ays changed when they were introduced to Western Culture and processed foods containing high levels of sugar They also began to work in sedentary jobs which altered their physical exercise In 1984 there was a forty percent rate of diabetes in the population of persons over 45 years of age (Patton 1986 : 36). The changes in diet and exercise patterns have altered lifeways of many persons in the Zuni population with diabetes In a research study conducted by Wilson and Leonard, 17 of 18 persons with Type II diabetes were able to reduce their average-fasting serum glucose (in Patton 1986 : 37) They were taken off of medication and controlled their diabetes with diet and exercise Individuals who were over 45 years of age were also participating in the project and accomplishing a healthier lifestyle (Patton 1986:39) This Zuni Diabetes Project demonstrates the high incidence of the disease in a population and the ability to control the complications of the disease by altered lifeways The elderly were able to participate and alleviated the iatrogenesis which often accompanies the disease process They were also able to prevent the secondary results of organ failure as a result of control of blood glucose

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36 Self-monitoring by the elderly is a problem because of the physical changes that occur which can be altered by prevention ofthe ravages ofthis disease Sensory Chan ges and Disease Changes in the senses are a norma l alteration in the aging process These changes are accompanied by disease processes which result in medical intervention The changes that affect the functioning of the elderly occur in the eyes, ears nose, taste and touch organs Diminishing neurons mitigate perception and transmission to the brain The neurons in t h e recepto r center of the brain atrophy which results in a reduction of chemicals and neuro t ransmiss ion (Saxon and Etten 1994b : 38-50) As a result of changes in visual receptors, more light is needed to stimulate the rods or cones which trigger nerve impulses to the brain (Saxon and Etten 1978a : 57) This higher visual threshold necessitates the need for greater illumination to obtain visual information from the environment (Saxon and Etten 1978a : 57) Visual ac u ity also diminishes in the a g ing process. This is caused by cellu lar changes in the lens, pupil, and vitreous humor (Saxon and Etten 1978a : 57) Accommodation is also diminished and this reflex change is called presbyopia (Weale 1985 :30 ) Presbyopia is the consequence of ocular changes which manifests as the inabi l ity to see close objects clearly The physiology of this process is complex and the crystalline lens is less responsive resulting in difficulty for the lens to change optical strength (Weale 1985 :30 ).

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37 The crystalline lens also becomes more yellow with age and it affects the quality of the retinal image by containing less violet and blue light which are both absorbed by the lens and it becomes fainter The aging lens remits violet light which is absorbed and casts a haze over the retinal image which degrades the quality (Weale 1985 : 31) The pupil gradually decreases with age with a reduction in its diameter. This curtails light beams from reaching the retina and only one-third of the illumination available reaches the eye of persons o v er age sixty as compared to those at age twenty (Weale 1985 :31 ) Greater illumination is beneficial, but more fluorescent light is counterproductive since it degrades the visual quality ofthe retinal image (Weale 1985 : 31-32) These age related visual changes can be altered by better illumination, magnification, and alteration of the environment (Weale 1985 : 32; Saxon and Etten 1978a : 60) The secondary problems related to presbyopia are the age-related disorders which include : ( 1) glaucoma; (2) macular degeneration ; (3) cataracts; and ( 4) diabetic retinopathy These disorders are the causes of blindness which prevent the elderly from participation in activities which include socialization This withdrawal from sensory stimulation results in isolation and psychological changes which include depression (Kane, Ouslander and Abrass 1989:301-309) Changes in hearing are responsible for the withdrawal of individuals from activities of daily living and results in diminution of social stimulation Seventy-five percent of the elderly have significant auditory and visual dysfunction (Kane Ouslander and Abrass 1989:301)

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38 Hearing loss in the elderly is usually of the sensorineural type which is due to damage of the hearing organ, the peripheral nervous system and/or the central nervous system (Kane, Ouslander and Abrass 1989 : 309) Age related sensory changes are called presbycusis which is a distinct progressive sensorineural hearing loss There is a deterioration in the hearing threshold with a gradual decline in sensitivity at high frequencies Hearing is mediated in the peripheral brainstem and cortical areas of the nervous system (Kane, Ouslander and Abrass 1989 : 314) Changes in the peripheral and central auditory system during aging lead to diminished hearing performance. The loss of sensitivity distortion of signals, and difficulty localizing signals are responsible for the inability to hear. The hearing threshold begins to deteriorate in the third decade of life. The gradual impairment is associated with a decline in sensitivity to high frequency sound and results in the inability to hear speech. Loudness is increased because of the inability of the elderly to receive information. This is a result of sensorineural loss due to changes in the hair cells ofthe inner ear (Kane, Ouslander and Abrass 1989 : 316) Neuronal hearing loss occurs when there is neuron cell loss in the auditory nerve (Saxon and Etten 1978a : 64) Metabolic changes cause the tissue in the cochlea to die due to insufficient blood supply. Mechanical hearing loss occurs when the ossicles and basilar membrane undergo degenerative changes and cannot move and transmit sound The eardrum also becomes thickened and less responsive to sound waves which prevents vibrations into the middle ear which impairs sound transmission

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39 Hearing loss and deafness cause individuals to become less resp ons i ve to their environment and less able to socially interact. They cannot participate in conversation and become withdrawn which causes sensory deprivation Depression has a twofold greater incidence in the hearing-impaired elderly (Herbst and Humphrey 1992). Hearing impairment can lead to social isolation fear, frustration and embarrassment which often manifests itself in low-self esteem and anxiety (Kart Metress and Metress 19 92 : 112) Cooper and Garsill ( 1992 : 112) reported research which indicated that deafuess may predispose to paranoid behavior (in Kart Metress and Metress 1992 : 112) Age-related changes in gustation, olfaction, and cutaneous senses produce loss of receptors These losses are responsible for less physical-sensory stimulation (Saxon and Etten 1994b : 68-69). The sensory reduction of taste and smell reduces pleasure which impacts mood These changes are also responsible for increased risk for accidents and death in the elderly population The Association of Chronic illness, Depression and Aging The proportion of older persons in the total population of the United States in increasing dramaticaily (Butler 1993 : 2) The 0lcest members of the baby-boom" generation are now fifty years of age and by the year 2011 one third of the population will be over age sixty-five These demographic realities coup led with the prevalence of physical change will result in more persons being afflicted with chronic illness.

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40 One of the most common emotional disorders among the elderly is depression and Butler ( 1993 : 2) asserts that the prevalence of mood disorders and depression may be as high as 3 1% in the elderly population The complexity of the mental and physical health status in this population further leads to difficulty in the diagnosis of depression The complexity and multiple interactions of concurrent disorders of the body and the mind may precipitate or be associated with major depression (Butler 1993 : 2). The aging process includes psychological social, and central nervous system changes which provide a high risk population The aging individual has an increase in the activity of monoamine oxidase (MAO) which is an enzyme that catabolizes neurotransmitters which are involved in the pathophysiology of depression (Steiner and Marcopulos 1991:585-586) Stress factors which include changes in lifeways cause a physiological stress response This stress response stimulates the production of epinephrine and norepinephrine (Selye 1976:81-82). Epienphrine and norepinephrine are catecholarnines which are produced by stimulation of the sympathetic nervous system Stimulants of the sympathetic nervous system are emotional responses to pain grief, anxiety fear relocation isolation, socio-cultural, and environmental change (Selye 1976 : 197-207) Aging is often associated with these adjustments of lifeways which are stressful and have a negative impact on the mental health of individuals (Steiner and Marcopulos 1991:586) Many studies have found a correlation between depression, poor health bereavement, and financial strain (Steiner and Marcopulos 1991 : 586)

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41 Stokes and Gordon (1988 : 16-19) developed the Stokes / Gordon Stress Scale (SGSS) which is a psychometric tool used to measure stress in persons 65 years of age and older. They reported that stress was not often measured in the population over sixty-five. Holmes and Rahe (1967) empirically demonstrated the association between life change events and the onset of illness The Schedule of Recent Experience Rating Scale (Holmes and Rahe 1967) does not adequately measure life events that are usually associated with aging development. The SGSS instrument predicted a 90 percent chance of illness in individuals over age 65 with scores of 300 and above (Stokes and Gordon 1988: 18). Leidy (1990 : 230-236) reported findings from a study which suggest psycho-social attributes, basic need satisfaction, and perceived stress together with the severity of disease may be contributing factors to the symptomatic experience of people with chronic lung disease. A statistically significant relationship was found between perceived stress and symptomatic experience (Leidy 1990:234). These findings support the hypothesis that stress may be expressed symptomatically in people with a chronic physical illness She also demonstrated an indirect effect of basic need satisfaction and psycho-social attributes on symptomatic experiences The statistically significant negative relationship between basic need satisfaction and perceived stress often produces a deficiency in motivation with feelings of threat anxiety, and tension (Leidy 1990 : 234) The results ofthis investigation support a better understanding of the mind-body / stress-illness relationship There is a great difference between the prevalence of depressive symptoms" and major depression in the elderly population (Blazer et al. 1987:281 )

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42 Persons over sixty-five years of age residing in the community were found to have only a five percent rate of major depression. The association between decreased life-satisfaction, bereavement, and depression has been suggested. These researchers reported eight percent of the elderly population had a current major depressive episode which included dysthymia, mixed depression, and anxiety, or symptomatic depression (1987:283). In contrast, nearly 19 percent of the community-dwelling elderly ( n-1 063) exhibited severe dysphoric symptoms (Blazer et al. 1987:283). Compared with the rest of the populations, a depressed person is likely to be female, white, somewhat less educated, and with a lower socio-economic status (Blazer et al. 1987:283-284). Individuals suffering from major depression complained more about poor health then the dysphoric group. Individuals were also described as having decreased life-satisfaction and being demoralized. The symptomatic depression group of four percent appear to be depressed secondary to the external stressors of poor health and death of a love one (Blazer et al. 1987:285 Table 4). It is further suggested that "future studies will increase the ability to identify depressive subtypes among the dysphoric elderly" (Blazer et al. 1987:286). Depression is a syndrome that is often silent and masked presenting itself in medically ill patients (Corbett 1984:22). Presenting symptoms may include: (1) hypochondriasis; (2) consciousness clouding; (3) pseudo-dementia; (4) failure to thrive; (5) fatigue; (6) alcoholism; (7) apathy; and (8) sleep disturbance. The differentiation between exogenous depression and biological depression is difficult.

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-+3 The history of the indi v idual and life events are critical to evaluate when the elderly individual presents with symptoms of depression (Corbett 1984 : 24) The elderly patient often presents symptoms of agitation and cognitive deterioration Karp (1988) argues for the symbolic interactionsists dictum that all meanings arise out of the process o f interaction which is ad o pted "People's subjective sense of aging arises from the range of communications from those immediately around them" (Karp 1988 : 737) The aging messages that are received are incorporated into the individual's sense of selfesteem. This frequently translates into worthlessness, hopelessness, anxiety, and somatization which are symptoms of depression (McCullough 1991 :73-74). Lyness and Caine ( 1994 : 15) note that depression in late life frequently presents with anxiety, somatic preoccupation, and significant comorbid medical illnesses Rapp and Davis ( 1989:252) present evidence that elderly persons with medical problems have a high risk for developing depressive disorders They previously had reported that depression rates in the geriatric medical patients ranged from I 0-45 percent. A low rate of recognition of the psychological comorbidity among geriatric medical patients was observed and noted (Rapp and Davis 1989:254) The evaluations included neurovegitative and psycho-social causes of depression, but screening for depression was not included. As a result treatment for depressive symptoms was not initiated. These researchers sug g ested routine screening of patients could be facilitated by the Beck Depression Inventory ( 1961) or the Geriatric Depression Rating Scale (Y esa v age et al 1983)

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-l-l Perception of situationa l control is a variable related to the morale of the elderly who are m institutional settings with learned helplessness as an underly-ing state in depression Learned he l plessness has also been associated with individual's belief that outcomes can be attributed to internal personal factors as well as external uni v ersal factors (Quinless and Nelson 1988 :11 ). Morale has been identified as the dependent variable in association with the exogenous variables of socioeconomic status and health (Ryden 1983 : 131 ) Ryden ( 1983 : 133 ) reported that perception of situational control, health functional dependency, and socioeconomic s tatus have significant direct effects on the morale of the elderly. In significant ep id emio lo gical studies which were done usmg rural and urban popul ations, the presence of depressive symptoms v aried from 9 percent to 29.7 percent (Blazer 1993b : Table 1-1: 1 3). A 16. 9 percent prevalence of significant depressi v e symptoms in the elderly intercity population residing in the Bronx, New York is significantly higher than nine percent in rural Iowa reporte d by O 'Hara. The information from both populations was gathered using the Community Epidemiological Study-0 (Blazer 1993b : Table 1-1:13-14) Results are remarkably consistent even though screening methods and instruments varied Copeland and his associates ( 198 7) reported an eleven percent incidence of depressive psychosis and neurosis in Liverpool England (in Blazer 1993b:Table 1-2 : 14) The lack of standardized method of case identification makes comparisons a cross the reported studies very difficult (Blazer 1993b : 1 3).

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-l5 In Blazer's study screerung instruments included : The Multidimensional Functional Assessment; The OARS Methodology; The Community-Epidemiological Study-D; The Zung SDS; and The Geriatric Mental State Schedule (Blazer 1993b : 13-14) These instruments all ha v e pro v en reliability and validity and are widely utilized in research settings to gather information about depressed populations Dysthymic disorders in older adults are highly prevalent and do not include the severity of symptoms which are found in major depression (Blazer 1993b : 195). As a result of a high incidence of depressive symptoms which occur, the Diagnostic Statistical Manual Disorders-IV has included a category 311 which is Depressi v e Disorder Not Otherwise Specified" (DMS-IV 1994 :350). This category includes dysphoric moods and the criteria for recognition of depression need only identify the presence of one or more symptoms (DMSIVC : 719) Snowdon and Cheung ( 1990) compared the Epidemiological Catchment Area studies with other studies and noted a frequent association of depression and physical health problems in elders They advised clinicians to be aware of masked depression" with physical symptoms Blazer also supports the research findings which noted that elderly persons with progressive symptoms were not diagnosed as clinically depressed (Blazer 1993b : 196). These findings further support the suggestion that depression is a hidden phenomena and produces somatic symptoms which often become the etiology of dysfunction in the elderly Waxman and associates (1985 : 50 I) further substantiate the association between non-specific somatic complaints and an underlying affective disturbance

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It also is suggested that these multiple somatic complaints are associated with depression The number of chronic illnesses is predictive of the significantly high rate of somatic complaints in the population (1985 : 503) Individuals who have more than three chronic illnesses have a statistically significant association with depression. The clinically reported relationship between somatic complaints and depression was empirically confirmed in the sample population of 127 community elderly The significant interaction between chronic medical illness and depression in predicting somatic complaints may suggest that the relationship between chronic medical illness, depression and somatic complaints is interactive and complex (Waxman et al. 1985 : 505). In a community based epidemiologic research study, Blazer and his associates (1987) categorized dysphoric symptoms into five subtypes: (1) major depression; (2) dysthymia; (3) a mixed depressive and anxiety syndrome; ( 4) more se v ere depressive symptoms; and (5) less severe dysphoric symptoms (1987 : 282) In one third ofthe elderly population which exhibited s y mptomatic depression, it was associated with the death of a loved one (Blazer et al. 1987 : 285). They were also more likely to have experienced social isolation and report social phobias Fifty percent of individuals who were suffering from major depression reported an increased perception of poor health subjective negative life events, and dissatisfaction in their social support networks (Blazer et al. 1987:285) In the total population of community elderly twenty percent were dysphoric These individuals did not exhibit all of the symptoms of major depression but were characterized as suffering from decreased life satisfaction.

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-+7 Anita Stewart and her associates (1989 : 911) observed significant nega t ive effects on most measures of functioning and well-being in patients who had chronic illnesses Their research was done on indi v iduals (9,385) who were over eighteen years of age and included the elderly. They funher reponed significant differences in mental health between individuals with any five (5) chronic health problems and those without. As a result of this research they recommend funher study of mental health in patients with chronic medical conditions General functioning and well-being are essential aspects of the quality of life for individual s Patients with depressive symptoms have significantly worse social functioning than those with each of eight chronic medical conditions (Wells et at. 1989:917). Role functioning is s ignificantly worse for individual s with depressive symptoms than for those who have as many as six chronic medical conditions. The depressive symptoms and chronic medical conditions have additive association s with patient functioning and wellbeing (Wells et al 1989 :9 18) This research demonstrates that "depressive disorder s and depressive symptoms are associated with limitation s in multiple dimensions of patient wellbeing, and functioning when compared with patients with no chronic conditions" (Well s et al. 1989 :918). The combination of the comorbidity of depressive symptoms and a medical condition is associated with twice the reduction in social functioning than with each factor alone.

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-l8 The morbidity of association with depressive disorder and symptoms support the need for assessment and treatment to alleviate poor patient functioning, suffering, and societal costs (Wells et al. 1989:918) Elderly wives who become care givers for their sick husbands are significantly depressed whereas men who are care givers exhibit less depression (Pruchno and Resch 1989 : 163) Although gender and role have often been associated with depression, wellbeing and burden have been suggested as variables which could be measured in association with depression This research demonstrates that caring for the chronically ill elderly is often a risk factor in the development of depression. There is considerable evidence relating lack of social support to depression (Blazer et al. 1987 : 285; Steiner and Marcopulos 1991:586; Smallegan 1989:45) Billings and Moos ( 1985) found less depression when family and marital support were present (in Smallegan 1989 ; 45). There is a significant need to further study the association of these variables with depression Although stress has been associated with depression the data have not been integrated to provide a clear understanding of their interaction (Smallegan 1989:45) Stress and illness have been associated with depression and dysphoria, but Addario ( 1985a) reported uncertainty as to whether the events precipitate the depression The relationship between the multiple variables of age, chronic illness and depression is complex and interactive The factors of exogenous and endogenous adjustment to life deve l opment produce affective changes in individuals. This affective alteration is a coping mechanism which supports the individual s adjustment.

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The multiple factors create a confusing clinical milieu which often prevents identification of the precipitating factors Identification of mood changes and intervention often prevents the development of cognitive changes in the elderl y The complex etiologic web' of causation of depression in late life is not necessary for effective treatment (Blazer 1993b :2 1 ) Therapeutic interventions have the potential to reverse or alleviate symptoms. The diagnosis and treatment are essential in the process of differentiation between depression and dementia (Blazer 1993b :2 52) This differentiation is essential in order to maintain the quality of life for elderl y individuals with depressive symptoms The presence of dysphoria and the contrasting low percentage of clinically depressed older adults produces questions related to etiology, recognition, and treatment of symptoms in this population The reported results of studies of depression often include : people who are clinically depressed; measurements of symptoms of depression; and depression including the levels of depression; and depression including the levels of depressive symptoms (Smallegan 1989:45). Other variables which are often associated with depression and dysphoria have not been adequately studied Depression in Culturally Diverse Elderly Populations Smallegan (1989) reported low rates of clinical depression m her sample population ( n= 181) of persons who ranged in age from 65 to 99.

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50 This elderly population was equally representative of males, females, blacks, and whites residing in a suburban area which reflected a broad spectrum of socioeconomic classes. The Geriatric Depression Scale (Yesavage eta!. 1983) and the Hopkin's Symptom Checklist were used to detect and measure depression Stressful life events were reported by 154 of the 181 respondents and 60 percent of the sample reported the death of a friend or relative (Smallegan 1989:47) They also experienced: illness of a friend; personal illness; accidents; recent relocation's; financial problems; and marital changes. One-third of the population also reported a major event other than those in the questionnaire Using the Geriatric Depression Scale in the measurement of depression, 20.4 percent of the population were considered depressed (Smallegan 1989:47) This is consistent with the reported studies of Blazer ( 1987). The findings indicate that 29 percent of the white population scored in the upper quartile and were considered to exhibit high levels of depressive symptoms (Small egan 1989:4 7). A significant relationship was found between the level of disability and the level of depression. Using logistic regression analysis, a significant relationship was found between the level of depression and the lack of a spouse. The total number of recent stressful events was also related to depressive symptoms. A major finding of this research is the significant relationship between race and depression, after controlling for the level of disability and living with a spouse (Smallegan 1989:48). The depression rates were lower for black respondents and much higher for the lower socio-economic white elderly (Smallegan Table 2 1989:4 7)

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51 The relevance of Smallegan's research is the establishment of a re l ationship between depression And culture when other life events are controlled. Although o t her research (Blazer and Williams 1980; Linn and Linn 1980; Waxman et al. 1985) establishes a relationship between depression and multiple factors, an association between depression and culture had not been established This research estab l ishes a significant relationship between culture and depression at p = O .OS (Smallegan 1989:48) Another ma j o r finding is the r eported association between depression and the total number of life e v ents living with a spouse, and stability Each of these factors when measured separately contributed to the presence of depressive symptoms in the population of dysphoric individuals (Smallegan 1989:47). The importance of cultura l characteristics and their measurements in relationship to mental health was introduced by Hazel Weidman (1978 : 1). The multiethnic character of a population was integrated in the Mental Health Ecology Project which was carried on at the University of Miami's Department of Psychiatry The proje c t integra t ed ethnicit y because of the need to reach populations in the mental health catchment areas served by the Center for Psychiatry at the University of Miami. The distinct multi ethnic character of South Florida's population required consideration as 'a crucial variable' in the research (Weidman 1978:9). Weidman (1978:9) defined ethnicity as group determination ofbehavior. Weidman suggested it would be wise to know what ethnic groups were r e siding in an area and what their special needs might be

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52 Health culture is the phenomena associated with the maintenance of well-being and problems of sickness with which people cope in traditional ways within their own social networks (Weidman 1978 : 13) This concept suggests the importance of integrating health beliefs and customs into the evaluation, intervention, and treatment of culturally diverse populations Ethnicity is seen as gro up determination of behavior and it influences morbidity profiles patterns of utilization evaluation and health care plarming (Weidman 1 978 : 9) The unicultural focus of the orthodox health care system often prevents successful intervention i n ethnically diverse populations (Weidman 1978 : 9) In the Miami Health Ecology Project the ethnicity of individuals was established in order to assess the continuity of enduring cultural experiences (Weidman 1 978: 129) The five groups studied were: Puerto Rican; Cuban ; Haitian; Bahamian' and American Southern Black The researchers established the importance of cultural variables and collected information which was deemed relevant. The variables included : ( 1) the birthplace of the individual ; (2) the relationship to a family member; and (3) the ethnicity match between a respondent's mother and father. Other important cultural variables ascertained were : (1) age and gender; (2) marital status; (3) activities which included jobs and school; (4) education; (5) occupation; and (6) religion (Weidman 1978 : 127-216) The Miami Health Ecology Project identified some of the problems associated with gathering informatio n related to ethnicity (Weidman 1978 : 135-139).

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53 Identification of differences within affiliated ethnic populations is essential for accurate data collection. Ethnic affiliation can be determined by consideration of the factors of: ( 1) language and dialect; (2) vocabulary; (3) behavioral preferences; (4) kinship networks; and (5) enculturation within established ethnic enclaves (Weidman 1978:137) Information related the use of traditional healers and treatment methods in ethnic populations is very difficult to establish (Weidman 1978 :27 3) She attributes the success of gathering data related to traditional healers and herbalists as the interviewing skills of their ethnic research assistants (Weidman 1978 :2 73 ) In the sample population of the Miami Health Ecology Project, depression was cited as a state perceived to be both physical and emotional by 7 7 percent of the respondents and the results were equally distributed by gender and age (Weidman 1978 :436). The descriptions included clinical signs of depression which are: weight loss ; feeling tired; an emotional state; and a feeling of dying (Weidman 1978:435) The integration of physical and emotional responses may be associated with the cultural perception of depression Baer (1992 : 5) suggests that the Mexican-American ethnic population seeks help from physicians for general depression or nervousness and they consult with relatives and priests for marriage and family problems. This researcher emphasizes the necessity to establish how the population perceives mental health when evaluations were made (Baer 1992 :6 -7). She relates the importance of recognition of the distinction between illnesses established by bio-medicine and those which are folk illnesses as described by Schreiber and Horniak (1981).

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5-l Acculturation has been suggested as the variable responsible for the difference in perception of good health reported by Mexican-Americans in the research study of Angel and Guarnaccia ( 1989) The physicians reported eighty percent of the population to be in excellent or very good health but onl y forty-eight percent of the respondents considered their health to be excellent or very good (Angel and Guarnaccia 1989) The Spanish speaking population of Mexican-American s reported higher levels of depression The traditional pattern of l ack of separat i on between the psychological and physical sense of self may explain why depression was self reported and not assessed by the ph y sician (Ange l and Guarnaccia 1989) The belief that high levels of affecti v e distress are a sign of negative physical health ma y also be a variable which explains the difference in identifying depression (Baer 1992 : 8-9) Baer (1992 : 15) suggests that studies of the domain of health and mental health as perceived by this population are lacking. She further states that it is "necessary to understand how the definition and perception of health and mental health in thi s population differ from those of the bio-medical system in the dominant culture (Baer 1992: 16) This further supports the need to collect data of ernie perceptions of mental health and how they differ from those of the dominant society (Newton 1978) Joseph and Shweder (1992:45) state that ideas about mental illness and the way persons express them to others is influenced by how a culture evaluates mental illness and its symptoms It is vital for researchers to identify the symptoms and know if a culture has a category for mental illness It is also necessary to identify those illnesses which may be more stigmatized than others

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55 Culture also influences how indiv i duals perceive emotions There is a vast range of cultural variation in emotion and ideas abo ut emotion Feelings are often expressed in varying ways across cultures Wierzbicka ( 1991) describes the expressions of feelings in five cultures : (1) Black American s ; (2) Polish-Americans ; ( 3) Jewish-Americans ; (4) Javanese ; and (5) Japanese The great difference is the attitudes related to the e x pression of emotions (in Joseph and Shweder 1992:48-51) The Polish Jewish, and Black cultures highly valued and encouraged expression of emotion s and in contrast the Japanese and Javanese frowned upon and discouraged this e x pression (Joseph and Shweder 1992:49) The expression of emotion and feelings of sadness i s also related to each society's collective experiences and how they affect individuals within the society. Polish respondent s in Wierzbicka's study suggested that depression, as defined by the questions, was a normal life occurrence It is suggested that this is related tot he trag i c history of Poland and has resulted in people who accept sadness as more normal (in Joseph and Shweder 1992 : 52) Cultural variation in identifying psychological changes and the integration with the physical self are vital aspects in establishing the presence of depression in the elderly population The traditional folk-diseases of cultures often describe symptoms which include anxiety, fear, pain, nervousness headaches and inappropriate behaviors (Baer 1992 : 9-13 ). These symptoms are often indicators of the presence of depression Individual psychological patterns which include coping styles society s cultural meanings and social responses and inequities in access to resources are deeply involved in shaping all forms of illness (Good 1992-1993 :430)

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56 Good (1992-1993) admonishes researchers to be aware of the reality that suffering is not divided between diseases of body, disguised with a veneer of cultural beliefs, and diseases of the mind, constituted by a society's culture-bound definition of abnormality and deviance" ( 1992-1993 :430). Good ( 1992-1993) offers the suggestion that research should be pursued to investigate : ( 1) the cross-cultural validity of diagnostic categories ; (2) specific differences in diagnostic criteria-cross-culturally; and (3) the role of culture in the diagnostic process ( 1992-1993 :430) The importance of basic research integrated with the role of culture, race, and ethnicity in psychiatric diagnosis is the theoretical framework of this study Aging, Chronic Illness, and Depression in Great Britain The population of persons over age sixty in the United Kingdom is 19.7 percent and those over sixty-five are 14.7 percent (Brocklehurst 1987 : 3). Epidemiological longitudinal Health Surveys which were done in Sweden by Waem (1978) indicate that between ages fifty and sixty men have dramatic increases in the development of chronic disease (Brocklehurst 1987 : 13) The diseases most prevalent are: (l) cardiovascular; (2) mental disorder; (3) endocrine metabolic; (4) nervous diseases; (5) musculoskeletal disorders; (6) respiratory diseases ; and (7) tumors (Brocklehurst 1987:13 Table 1-7) These diseases are the most prevalent in the industrialized nations ofthe world.

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57 The incidence of disability and dependence res ultin g fTOm these diseases in the United Kingdom is reported t o be as high as 51.5 percent in the female population over age seventy-five and 36.3 in the males ofthe same age (Brocklehurst Table 1 10 15) There is a dramatic change in functional capacity as individuals age. The elderly in Great Britain have increased fivefold and represent 15 percent of the total population (Arie 1981a : 557-558). In the industrialized world the growth of the population over 65 is 24 percent in contrast to 1 2 percent of wor king and sc h ool age persons Even in th e developing world the over 65 year old populat ion is ten percent higher than the working and sc hool age population (Arie 1 981 a : 558) Fertility rates are dropping worldwide and it is estimated that the aging population will be 20 percen t b y th e year 2001 (Cat e l y-Carlson 1 992 : 420). Forty percent of all health care expenditures in Canada are fo r the elderly (Cately Carlson 1992:420). The major diseases of all the indu stria l ized world are diabetes, cancer, and degene rati ve diseases (Cately-Carlson 1992:421 ). The problem that arises from this reality is that chronic diseases do not cause mortality but produce morbidity resulting in difficu lt y for aging individuals to cope and adapt. Brocklehurst ( 1987 : 1 6) reports that epidemiological s tud ies meas urin g aging rates in humans in clude anthropometric measurements, physiological and biochemical t ests, and psychometric tests. He notes that psychometric tests are not culture-free and shou l d be administered o nl y t o EuroAmerican and Japanese populations for which they were developed

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58 The incidence of chronic illnesses experienced by the population over age sixtyfive of Great Britain has been reported to be 50 percent (Arie 198la:558). Half of all hospital beds are occupied by the elderly and the over 75 age group has an average of six different illnesses with serious limitations (Arie 198la:558) Arie (l98la:558) notes that chronic confusional states can be altered by meticulous diagnosis and specific treatment. Abrams strongly argues that the greatest anxiety of the elderly and those who care for them is their health (Arie l98la: 558). Many studies in Great Britain suggest that age-related changes m cognitive functioning may be due to changes in physical health associated with age. Their st ud y suggests that physical exercise, such as walking, may enhance and maintain cognitive functioning This research reported that more older men than women reported their health as poor. Psycho-Geriatrics became a specialty of the National Health Service in Great Britain by 1989, although it was recognized 25 years before (Arie 1994b :8) Care and services for aged mentally ill pe rsons are widely established. The psycho-geriatric consultants have been providing local psychiatric services for the elderly (Arie 1994b:9) The typical progran1 includes ps ychiatric physician consultants who prov ide services to community nursing social services, psychology, housing departments staff, family doctors, geriatric medical services, and other facilities (Arie 1994b:9) There is a major emphasis in teaching old age psychiatry and as a result psycho-geriatricians provide services for health care providers This integration provides a holistic approach to geriatric mental health

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This holistic program includes : Assessment, diagnosis, hospital liaison, treatment, and rehabilitation Long Term and intermittent care Continuing Care Support for Care givers Planning Advocacy/Liaison/Fund-raising-other services Voluntary Private Non-health profession Government the public" The Media Advice (legal, ethical, financial) Education Research (Table 2 : 1 Arie 1994b : 9) 59 The role of advocacy for the elderly integrated into service provision results in a more unified health care delivery service for the elderly in the United Kingdom (Arie 1994b : 121-124) The service provision includes collaboration with other agencies which contribute to the welfare of the elderly (Arie 1994b: 122)

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60 The team includes physicians, psychiatrists, psychiatric nurses, social workers, clinical psychologists, occupational therapists physiotherapists, speech therapists, chiropodists, and support staff(Arie 1994b : l 23) Specialists in internal medicine and genera l practice collaborate with the geropsychiatrists while other medical specialists do not have close links (Arie 1994b ). For Arie, th e ideal set ting is the department of Health Care of the Elderly which is established in Nottingham at the Queens University Medical Center (Arie 1994b) In Great Britain the community psychiatric nurses a re an important bridge' between the specia list service and the primary care providers (Arie 1994b : 124) This plan of intervention provides h olistic care service for the elderly The psycho-geriatricians and the Health Care of the Elderly Center at the Nottingham Hospital provide services to the rest homes and nur sing homes in their district (Arie 1994b : 125). These service s provide support and intervention for patients, families, staff and professionals working with the chronically and mentally ill in long-term care facilities (Arie 1994b: 127) The inclusion of speech therapy, physiotherapy, dentistry, chiropody, and psychotherapy has enhanced care giving for elderly patients in all sectors of service provision in Great Britain Arie (l994b: 128) suggests that the identification of mood disorders is essential in order to provide treatment which would prevent further dysfunction Social services departments are charged with identifying patients in need, assessing what they require, and making services available (Arie 1994b : 131 ).

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61 Sir Exton-Smi th ( 1979:26) reported that many elderly patients in whom multiple pathological processes are present, admitted with both physical and psychiatric symptoms, were inappropriately placed and tre ated. When patients are treated in appropriately the mortality rates increase and the need to assess the mental status in imp erative. The p sycho geriatric assessment and treatment is the result of planning for the observed needs of the elderly (Exton-Smith 1979 : 26) Arie (9181a) described a comprehensive psychiatric service for the elderly which includes care for persons with physical and behavioral problems of such significance that they need joint medical and psychiatric care which necessitates medical treatment (in Exton-Smith 1 979:27). The psycho-geriatric units are co-lo cated with geriatric units in the District General Hospitals. The status of the elderly has been identified as a major component of self-esteem (Arie l 98la:560). The perception of lower status is the result of Western societies' high regard for attributes of youth (Arie 198la:560). The technological societies produce change which is the antithesis of experience. This lack of regard for the aging process and the biological changes which res ult in physical demise create a negative self-concept for agmg persons. The elderly population in the United Kingdom had hard lives (Arie 198la:559). They are s urvivors of three wars and a depression and experienced poverty, hunger, and unemployment (1981:559) These individuals have adapted to hardships and ask very little and express gratitude for what they have (Abrams 1978). Arie (1981a:562) suggests that aging includes chronic disabilities bereavement, and other privations.

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62 He further suggests that copmg st rategies include chronic depression, paranoid embitteredness, and a breakdown. These coping strategies can be altered to produce more old people who are resilient, self-sufficient, and happy. The rearing of resilient, attractive, old people may be the major challenge in preventative medicine. As a result of research and recommendations reported by Arie (1981a : 562), the psycho-geriatric and geriatric services in the United Kingdom are integrated to pro vide holistic services in the communities. Each elderly person is served b y a general practitioner and community health team. When patients are in need of psychological, social, environmental, and medical care they are assessed and intervention is provided This service provision may be provided at the community level or in the District General Hospital geriatric-geropsychiatric centers The goal s of the centers include interaction with the elderly and concern for them which is a natural component (Arie 1981 a : 562) Aging. Chronic Illnes s and Depressio n in Native American Populations The elderly Native American population in the United States has been a neglected ethnic group in the sense that studies have not included them As a result their special needs have not been addressed (Manson and Pambrun 1979: 19) In 1971, during the Western Conference on Aging, several Indian members of the National Council on Aging's Board of Directors focused federal attention on these needs (Manson and Pambrun 1 979: 19) Advocacy for the Indians was carried forth in a Special Concerns Session on the elderly Indian at the White House Conference on Aging.

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63 The Special needs of the elder Indians were established within eight categories : (a) income; (b) housing ; (c) legal problems; (d) nutrition; (e) nursing homes ; (f) health ; (g) transportation; and (h) education, physical and spiritual well-being (Manson and Pambrun 1979 : 19). The recommendations which were specific to mental health called for funds to organize and conduct culturally oriented activit ies ranging from (a) social clubs to educational clas ses; (b) employment of the elderly as resource persons within culture preservation programs; (c) matching of age sex, and tribal background of social service providers with elderly recipients; (d) reorientation of service delivery to individual home care as opposed to institutionalization ; and (e) support of traditionally therapeutic meth o d s of modify i n g drinking behavior (Manson and Pambrun 1979 : 19) On September 17, 1976, (A report of the Special Committee on Aging, United States Senate Part I: 179-180) : "The Administration on Aging entered into a working agreement with the Office of Native American Programs designed to im prove a four-prong approach to: 1 Expand knowledge about the living conditions and needs of aged Indians and test alternatives for meeting those needs. 2. Heighten awareness ofthe cultural needs and problems faced by other Indians especially by governmental agencies with resources to serve this group. 3 Increase the involvement of Indian tribes and organizations in the development of policy, planning, and prograrrurung for older Indians at all leveis of government.

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6-l 4 Expand government resources to serve the needs of elderly Indians and increase the number of Indian tribes and organizations receiving funds directly for purposes of providing services for the aged" The Senate Special Committee recognized the social and economic poverty of the Indian elderly in their recommendations (1976: 180) Manson and Pambrun ( 197 9 :21) reported that the Advisory Council on the Elderly American Indian (U S. Senate 1971) emphasi z ed the mental health benefits of Indian family solidarity They also note that McClure and Taylor ( 1975) report the value of psycho-social support that members of the family derive from the elder There is evidence that the family is an important element in the emotional stability of the widowed Indian elder (Chevan and Korson 1972:45-53 ) Manson and Pambrun ( 1979 :22) further report that research indicates Indian elderly could be the most deprived identifiable group of American citizens (Hill and Spector 19 71; Bell, Kasschau, and Zellman 1978 ; Benedict 1972) A survey of the National Indian Conferences on Aging Participants collected data about physical status, service utilization, self-image, and perceptions of the family and comm unity response to elderly needs Although this sample was not representative of all Indians, the participants were selected for their ability to articulate local concerns for many elderly Indian tribes (Manson and Pambrun 1979 : 23). This survey concurred with previous research which identified Indian elderly as vulnerable The results of the survey indicate Indian elders wish to be active, to be selfsustaining, and to choose how and where to live with personal dignity

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65 There are reports in the literature which substantiate that most elderly Americans live in their own homes and eight-four percent of them live within one hours drive from their children (Riley and Foner 1968). Indian natives who reside on reservations live near at least one or more children and see them frequently (Manson and Pambrun 1979 : 23) This information has remained consistent in recent years for the elderly Indian as well as other American elderly. They do not want to reside with their children, although the family still remains a major support network for elderly Indians and other Americans (Manson and Pambrun 1979:23) Studies indicate the increase number of elderly persons in older individuals' social sphere reduces feelings of isolation (Manson and Pambrun 1979 :23). Elderly Indians report feelings of isolation when they reside off the reservation Manson and Pambrun ( 1979:23) report that family relations become more positive in the dominant culture when the elderly have more contact with other older persons. They suggest further research to detennine if a similar condition applies to the Indian elderly. Manson and Pambrun ( 1979:24) also indicate that the social gerontological research has identified several major contemporary pressures which affect the elderly American. They are a decline in work and employability, the development of agestratification, and the relative weakening of kinship ties. As a result the elderly are seeking support and approval from other elderly Americans outside of the family. Manson and Pambrun (1979:24) strongly suggest that American Indian elderly may be subject to the same pressures as reported in the dominant culture and it is time to inquire about their social psychological interactions.

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66 Physical illnesses, both chroni c and acute, constitute one of the greatest problems which face the American Indian and Alaska Nati v e populations (Baron et al. 1 9 88 : 217 ) Among this population the impact of these illnesses results in high rates of disability and inability to perform daily activities Baron reports much higher rates of depression in this population when compared to older non-Indians They also substantiate the prevalence of depression in the general population of elderly increases in persons sufferin g from chronic disease There is a need to study Indians and Native Americans in order to further correlate chronic disease as a major factor in depressive symptomol ogy (Baron et al. 198 8 : 217) Baron (1988 : 217) studied the Confederated Tribes of Warm Springs, Oregon; the Yakima Indian Nation Washington; the Lummi Nation Washington; and the Nooksack Tribe of Puget Sound They admini s tered a health screening interview, The MarlowCrowne Social Desirability Scale a subjecti v e health status questionnaire, aspects of daily living inventory, Health Locus of Control Scale, indices of perceived pain health care utilization and satisfaction, Life Satisfaction Index-A, and social support systems survey The Center for Epidemiological Study-Depression Scale was chosen to assess the presence of dysphoria as well as other cognitive, affective, psycho-physiological, and behavioral symptoms of depression (Baronet al. 1988 : 222) This instrument was chosen because it specifically was developed for community-based applications (Baronet al. 1988:222) Radloff (1977) reported an internal consisten c y coefficient of 87 for the CES-D (in Baron et al 1988 : 222)

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67 This instrument has been factor analyzed to determine which items on the scale are correlated with each other. Roberts ( 1980) reported the same results in a multi-ethnic community. Baron ( 1988 : 229) and her researchers reported that the internal consistency of the CES-D is a consistent measure of depressive symptomatology in this group of older American Indians with chronic disease (Baron et al. 1988 :229) This study was the first to report this finding The authors suggested further research with elderly American Indians who are chronically ill in order to fully assess the strengths and limitations of the CES-D in measuring depressive symptomatology in this special population. Manson Walker and Kivlahan (1987 : 167) report that depression and adjustment reactions are often associated with alcohol abuse and chronic illness and disabilities The authors point out that the psychiatric assessment often does not describe the relationships between mental health status and "other phenomena, such as cultural change, alcoholism and physical well-being" (Manson, Walker and Kivlahan 1987 : 167) In mental health centers located on reservations, the Indian Health Service reported that thirty-eight percent of the visits were attributed to anxiety, adjustment reactions, and depression (Manson, Walker and Kivlahan 1987 : 167). Urban Indian health clinics reported sixty percent of presenting complaints were attributable to mental health problems (Manson, Walker and Kivlahan 1987 : 167). Sue (1987) reported that in seventeen community health centers in Seattle the Indians and Native American patients did not return for treatment after initial contact. This was significantly higher than other minority populations

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68 Manson, Walker and Kivlahan (1987 : 168) discuss the validity ofinstruments which are used in Native American populations to collect data which were developed for use in the dominant American culture Chance ( 1962) analyzed and reported the validity of the Cornell-Medical Index and found that some questions were culturally inappropriate and did not measure information accurately (Manson, Walker and Kivlahan 1987 : 168) Martin and colleagues ( 1968) reported consistency and validity when using the Cornell Medical Index, but they were wary of the use of the words "usually and always" since they are not culturally accepted by American Indian populations they interviewed (Manson, Walker and Kivlahan 1987: 168) The National Institute of Mental Health Diagnostic Interview Schedule (Manson, Walker and Kiv l ahan 1987 : 169) is a highly structured instrument which was designed to allow interviewers to render 26 psychiatric diagnoses according to Diagnostic Statistical Manual-III criteria ( 1980a) It is descriptive rather than an etiological approach to diagnosis and defines clear standards of severity of symptoms (Manson, Walker and Kivlahan 1987: 169). This structured psychiatric interview is relatively new and only systematic studies of the instrumentation have been reported by Manson, Shore, Bloom and their associates (1985) The psychiatric assessment and treatment of American Indians and Alaska natives have entered an exciting period of advancement. "Culturally appropriate adaptations of instruments are being made and guidelines for their interpretation are emerging" (Manson, Walker and Kivlahan 1987: 172)

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69 These researchers also indicate that reliability and validity of other clinical measures in assessment of this special population will attract similar study (Manson Walker and Kivlahan 1987: 169) Kinzie and Manson (1987 : 194) suggest there is no substitute for thorough clinical interviewing They also state that the self-rating scale may be a helpful adjunct to the clinical interview These researchers also state that some biological symptoms of depression are present in all cultures (Kinzie and Manson 1987: 194) It is also important to note that subjective, psychological aspects of depression are much more influenced by culture and language and vary across cultures" (Manson et al. 1987 : 194). Scale items that address symptoms are recommended as more valid to collect data related to psychiatric symptoms (Manson et al. 1987 : 194) Shore and Manson ( 1981 : 5-1 0) describe the indigenous concepts of depression and culture bound disorders They remind the readers that there are many varied Indian cultures from the Bering Sea to the Everglades of Florida. They present the most common symptomatology and identifY the groups who report these phenomena Windigo Psychosis has been observed among the Cree Eskimo, and Ojibwa Indians of Northern Canada (Parker 1960 in Shore and Manson 1981 : 6) This disorder has symptoms of melancholia and a compulsive desire to eat human flesh This delusion promotes the person to feel that he/she has been transformed into a giant monster that eats human flesh. These symptoms have been associated with self-deprecation and the need for punishment (Kiev 1971 in Shore and Manson 1981 : 7)

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70 The Hiwa-Itck Syndrome as described by Devereux (1961) is a depressive syndrome of elderly Mohave men who have been deserted by younger wives It is viewed as a heartbreak which may cause death (Shore and Manson 1981 :7) Wacinko syndrome among the Oglala Sioux as described by Lewis (1975) "is a well defined an indigenously recognized reaction pattern". It is a syndrome with reactions of varying intensity, with degrees of anger, pouting withdrawal, feelings of despondency, a slowing of bodily movements, loss of speech, immobility, and occasionally suicidal behavior. This syndrome is diagnosed as a mild to severe reaction depressive illness (Lewis 1975) Nez Perce Self-destructive Behavior is a behavior which takes place in the populations of Native Americans in the Pacific Northwest of America It is associated with depression and suicidal ideations (Shore and Manson 1981 : 7) Tawatl Ye Sni is a cultural disorder which has been described among the Dakota Sioux of North and South Dakota It is a pattern of behavior that is prevalent in other plains Indian tribes. The disorder includes behaviors of: deprivation, losing one's mind to the dwelling of one's dead relative, a past orientation, thoughts of death, sending one's spirits to the ghost camp by willing death committing suicide, or drinking to excess, preoccupation of ghosts or spirits, and expression of hopelessness (Johnson and Johnson 1985). Excessive Navajo Mourning is associated with a higher incidence of pathological grief reactions Navajo patients show symptoms of depression, including biological changes such as weight loss and sleep disturbances (Shore and Manson 1981 : 8)

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71 Forty percent of clinical depression among the Nav ajo has been attributed to this grief reaction which is thought to be a reaction to repression of normal grief and emotion (Miller and Schoenfield in Shore and Mans on 1981 : 8) When a diagnosis of depression is assigned to a Native American person, an essential questio n i s "from whose viewpo i n t ? (Shore and Manson 1981 :8). The ernie view of the etiology of symptoms often identifie s untoward beha v iors as a result of normal life adjustment s. A culture bound s y ndrome may be the result of a variety of stressful events The behavior s that are manifested as a result of this reacti v e stress are alcoholism, suicide, destruction of property, family negl e ct, and other social conditions (Shore and Manson 1981: 8-9). Depressive behaviors are pervasive component of emotional distress among Native Americans (Shore and Manson 1981 : 9) Kraus and Buffier reported that "overt depression was most common among Eskimos and particularly frequent in larger villages" (Shore and Manson 1981 : 120-122) Researchers have found thirty to forty percent of all mental health problems were directly related to a depres sive behavior (Kahn and Delk 1980; Schoenfield and Miller 1980 ; Kinzie Shore and Pattison 1988). Most of the depressed respondents were female between the ages twenty and forty. Shore and Manson ( 1981 : 11) present evidence that differences in the American Indian subcultures significantl y affect behavior and recommend future research which emphasizes both sub-cultural specificit y and multiple etiologies of depressi v e reactions

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72 In a study done in 1988, Kinzie and his colleagues replicated a psychiatric epidemiological study of an Indian village which was done in 1969 (Kinzie, Shore and Pattison 1988:3339). The most impressive finding was alcohol-related problems and dependence which affected 75 percent of the population. Another important finding was the prevalence of affective disorders with recurrent major depression The lifetime prevalence dysthymia was four times more common in the 1988 study and affected woman twice as much as men (Kinzie, Shore and Pattison 1988 : 37) These rates ofprevalence of mental disorders are much higher when compared to the Epidemiologic Catchment Area Study. The rates are 69.4 percent for a lif etime prevalence in the Indian Village compared to 32.2 in the ECA studies (Kinzie, Shore and Pattison 1988 : 38) These recent studies confirm the presence of both alcohol-related disorders and affective disorders in Native American communities. In a population of Indian residents who belong to a Northwest Coast culture group, Somervell and his associates (19921993 : 511-512) found comorbidity of affective disorders and alcohol abuse present with a positive relation although not statistically significant. Factor analysis revealed a high correlation between depressed affect and somatic distress (Somervell et al. 19921992:511-512) Western scientific culture separates affective and psychological states from bodily sensations (Somervell et al. 1992-1993 :511 ). Kleinman and Kleinman ( 1985) state that this is not a universal way of structuring an experience Somatization of depression is common and often it is normative and expressed in physical distress (Somervell et al. 1992-1993:511).

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73 The comorbidity and understanding of how these disorder s manifest themselves o ver the individual life spans in the cultural environment are valid and compelling subjects for future study (Kinzie Shore and Pattison 1988 :39). Baker and his associates collaborated to write a chapter in Aging and Rehabilitation (Brody and Pawlson 1994: 186-207) They identified the growth of the ethnic population of elders in the Untied States. They also recognized the complexit y of the sub-populations within the Afro-American, American Indian, Asian American, Pacific Island, and Hispanic ethnic groups (Brody and Pawlson 1 994 :205). They s u mmarize by reminding the therapist that the ethnic e l der may have his / her own explanatory models of illness which differs form Western medicine They also emphasize the importance of knowledge of history and sensitivity to cultura l definitions of illness and health care American I ndians sixty five years of age and o lder will double by the year 2 ,000. They represent five percent of the Indian population which totals 1. 5 million (Baker et a!. 1994 :191 ) More than half of the tribal members live off the 278 reservations and 209 villages in the United States. In contrast, the majority of elderly American Indians still tend to reside in rural reservation communities (Baker et al. 1994 : 191 ) These elderly Indians live on an income which is 40-59 percent lower than that of older whites. The elderly Indians who live on the reservations have 70 percent less income than urban elderly Indians Three-fourths of rural American Indians between ages 65-74 live with their families, while 50 percent of urban Indians live w ith their families Only eighteen percent of all elderly persons in the United States r eside with their families (Baker et al 1994 : 191)

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7-l The authors present the social realit y that as Native American people age, the likelihood of living alone increases. At leas t one third of aging rural and urban populations of both white and Native Americans reside alone. Urban Indians live in institutional environments at double the rate of rural elderly Indians Baker ( 1994: 192) suggests that physical health problems play a large role in the lives of older American Indians Seventythree percent of the elderly Indian population is estimated to be mildly to totally impaired in their ability to complete activities of daily living. Chromic illne sses are more prevalent in this population than among non-Indians (Baker et al. 1994 : 192) Forty-one percent of American Indian elderly were treated by traditional healer s and sixty-three percent practiced their own cultural forms of self care (Baker et al. 1994 : 193) When presenting data relevant to the rehabilitation of Native American elders, Baker and his researchers found that as physical illness worsened they felt the cause and control were beyond their immediate control. The respondents cited major strengths in enabling them to cope with their illnesses. They are in descending order of importance: religion, family, spouse, friends, and health care profes s ionals (Baker et al. 194 : 193) The availability of a confidant was strongly associated with an older person's degree of life satisfaction. Eight-two percent of their respondents reported having a relationship with a confidant. Manson, Shore and Bloom ( 1985) did studies integrating the study of depression among the Hopi by eliciting and comparing local explanatory models to Diagnostic Statistical Manual-III (1980b) c riteria for major depression They were able to demonstrate the manner in which Hopi categories of illness relate to this psychiatric disorder.

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75 We have established the fact that there is broad variation m i\ative American communities, tribes, bands, nations, and individuals This cultural diversity creates a difficulty in the method of establishing variables related to illness and specifically psychiatric syndromes There are pan-Indian cultural characteristics which with qualifications are consistent among all American Indian groups (Connelly 1988) These characteristics are : a respect for individual freedom and autonomy ; b. a tendency to seek group consensus, not majority rule; c respect for the land and all living things, and an appreciation for their contributions to Native American lifestyle; d a propensity for demonstrations of hospitality and re s pect; e a dictim that 'one should a v oid bringing shame on oneself, family, clan or tribe'; and f. a belief in a supreme being and life after death" (Connelly 1988: VI-1 0). This study integrates the variables which ha v e been identified by researchers who presented data which indicate associations with illness and psychiatric disorders. There is strong evidence that support systems and networks, confidants, family community, respect hospitality, religion and autonomy are essential for the well-being of Native American elderly persons These strengths enable older persons to have greater life satisfaction which is a predictor of reduced symptoms of dysphoria

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76 Summary Each of the topics reviewed in Chapter 5 is related to culture Good and Mezzich ( 1994) present guidelines for complementary cultural formulation related to the place of culture in the Diagnostic Statistical Manual-IV ( 1994c ). The cultural identity of the patient, the cultural explanations of the patient's illness, the cultural factors related to psycho-social environment and functioning, and the intercultural considerations on the provider-patient relationship are recommended to be included in the cultural assessment for diagnosis and care (Good and Mezzich 1994) It is essential to integrate culture into the identification of depression and the mitigation of symptoms in elderly populations Each of the topics reviewed identifies important aspects which have a relationship to the development of dysphoria and depression in aging persons. The major objective of this study is to present data which support the presence of depression in the selected populations, to identify the symptoms which are culturally specific, and understand the variables which may contribute to the mitigation of this mood disorder. Another major contribution of this study is to evaluate instruments used to collect data and test their cultural sensitivity. Each of the categories of diagnostic criterion need integration of culturally distinctive feelings, expressions, and experiences into the Diagnostic Process This can only be accomplished with further data to support cultural variation in diagnosis and treatment of psychiatric disorders This study may contribute to the Major Cultural Enhancements ofDiagnostic Statistical Manual IV (1994).

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77 CHAPTER3 METHODS Introduction The purpose of the present study is to clarify the association between depression, the presence of chronic illnesses and cultural differences in elderly populations. There is a strong association between chronic illness and the presence of depression in older persons. A major aspect of the study is the identification of ethnic-cultural lifeways which may affect perception of physical change and mental status alteration in the elderly. The recognition of cultural variables associated with the presence of depression may provide for mitigation. This is the basis for the method and materials selected for the research. In order to identify significant variables, the Social System Model and the Causal Model have been applied in order to identify the cormectedness of the variables which are presumed to act in a causal marmer with the most important variables affecting a dependent outcome (Miller 1991:52-53) The Causal Model is used in order to construct a simplified model of social reality This is done in order to identify the most important variables affecting the dependent variable The Social System Model maximizes analytical attention to the cormectedness of the variables (Miller 1991 :52-53)

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78 The variables relating to age, chronic illnesses and culture are evaluated in selected populations which demonstrate integration into their communities with identified boundaries The variables related to culture include : (1) number of children; (2) number of grandchildren; (3) number of visits from children; ( 4) number of visits from grandchildren ; (5) where and with whom the individual resides ; (6) work status; (7) medical expenses; (8) the number of friend s visits; (9) marital status; (10) gender; (11) years of education; (12) languages spoken; (13) culture; (14) religions ; and (15) income Information related to the number of chronic illnesses and the presence of depression were also collected from each respondent. Groups Studied Information was collected from people over the age of fifty-five active and participating in activities in ethnically distinct communities The first population studied is the Tewa Pueblo Native Americans who reside at the San lidefonso, Pojoaque, Tesuque, Nambe, San Juan, and Santa Clara Pueblos in the state of New Mexico in the United States The subjects selected are representative of a non-dominant culture who have their own tribal government and practice their traditional religion and customs as well as Roman Catholicism They are descendants of the Tewa and the art of pottery-making has been passed from generation to generation The languages spoken by these people are English, Tewa and Spanish There is a great deal of inter-marriage between Pueblo people and other Native American tribes (Frisbie 1981 : 25-35)

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79 F i fteen respondents were interviewed at the Senior Congregate Dining Program site. It is located in the center of the San Ildefonso Reservation next to the Roman Catholic church of San Ildefonso and across the street from the kiva All members of the Pueblo are invited to participate if they are fifty-five years of age and older This program is administered by the Tribal Council in partnership with The Federal Congregate Dining Program These respondents were informed about the purpose of my visit and the study and volunteered to be interviewed All participants are active and selection was based on their willingness to participate, their ability to answer questions, and being representative of older men and women residing in the Pueblo Many of the respondents invited me to their homes to meet other members of the families who were interviewed They also invited me to several festivals which were being celebrated during my residency in New Mexico This provided an opportunity to collect information from respondents who are actively involved in participation in cultural events and who are Tewa married to residents of other pueblos All of the respondents are able to carry on activities of daily living and are independent. The second population studied is a group of English people residing in Lincolnshire England They were selected because they are representative of nonAmerican culture The respondents were selected because they are over age fifty-five, willing to give information and easily accessible to the researcher These respondents were selected from participants at the local congregate dining and activities centers which are located in the cities of Grantham and Nottingham

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80 This population of informants is representative of individuals residing in a postindustrial society which provides health and social programs for all elderly persons who reside in Great Britain These individuals are recommended for the congregate dining and social sites because they are referred by their health visitors, physicians and/or social workers Each individual in the United Kingdom is provided with this unique team of health care providers who are involved in health management for the total population They have many support programs for the special needs of the elderly and the participants have been referred because they are at risk of developing other problems without this intervention All of the participants are able to reside independently and carry on activities of daily living The population which is representative ofthe dominant culture in the United States is a group of Euro-Americans who reside in Polk County, Florida In order to be selected individuals had to be residents of Polk County, Florida for more than 25 years Data were collected from respondents who are over age 55, living independently, and participating in the Multi-Purpose Senior Center of Polk County Selection was based on availability of respondents their ability to answer questions willingness to participate, and being representative of the total population of participants These populations were evaluated by gathering information from respondents who were selected at the sites described Quota sampling was the method used to select the respondents in the population which was available (Polit and Hungler 1989 : 172-173) The individuals were chosen to be representative of males and females in the population which was available

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81 They were also selected to be representative of individuals who are defined as "young old, middle age old, and old old", which are chronological age categories (Neugarten and Moore 1972 : 5-25). They also are individuals who are able to answer the questions and willing to participate in the process of data collection Respondents were informed about the consent form which provides protection of individuals who voluntarily participate in this study (Appendix V). All of the respondents had chosen to participate in the programs at the senior center Some had been referred by their health care providers These individuals are all able to live independently and carry on act i vities of daily living Data Collection Instruments The Geriatric Depression Rating Scale (Short Form) (Sheikh and Yesavage 1986a, Appendix III) and the AIDE (Age, Depression, Illness and Ethnicity Biographical Questionnaire Larnm 1989 Appendix I) were administered to the respondents. The AIDE Biographical Questionnaire was developed for this study in order to collect biographical data which related to the identified variables The Bloch Ethnic/Cultural Assessment format was selected to obtain ethnographic information which may give further data associated with culture and depression (Appendix IV) The Multidimensional Functional Assessment (OARS) was used to co lle ct data related to presence of chronic illnesses (Appendix II)

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82 The Age, Illness, Depression and Ethnicity Questionnaire (AIDE) The Age, Illness Depression and Ethnicity Questionnaire (AIDE) was administered to obtain biographical data from the respondents (Lamm Appendix I) The information was collected from selected informants who are representative of the populations sampled, living in their communities and participating in activities of daily living The Multidimensional Functional Assessment (OARS) The questionnaire used to obtain the number and severity of illnesses the individual developed is derived from the list designated for use in the Multidimensional Functional Assessment for the Study of Aging and Human Development (OARS: Duke University Center for the Study of Aging and Human Development 1979 :93, Appendix II) The basic OARS instrument is used for the assessment of individuals living in their own home or residence. The reliability is reported as adequate and the validity in physical and mental health is good (Multidimensional Functional Assessment: The OARS Methodology : A manual1979 : 21) Content and consensual validity of the OARS were insured by the manner of the construction of the instrument. Concurrent criterion-related validity was established by correlating the assessments of geropsychiatrists and mental health scores; the Spearman Rank Correlation obtained was 0.67

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83 Interrater reliability using intraclass correlation coefficients from an analysis of variance of subsections ofthe OARS ranged from 0 66 to 0 86 (Foxall et al. 1987) The list of diseases in the OARS requi r es a simple response of" yes or no with some subjectivity related to (1) not at all; (2) a little; or (3) a great deal The response reliability has been established (OARS 197 9 : 43) Information is based on the subjects personal responses and therefore all respondents were carefully instructed about the diseases and the process of stating if they have the diseases and if so how great. The Geriatric Depression Rating Scale (Short Form) The Geriatric Depression Rat i ng Scale (Y esavage et al. 1982-1983, Sheikh and Y esa v age 1986a: 3 7 Appendix III) was administered in order to measure the presence and severity of depression in these populations of persons over 55 years of age The instrument was selected because i t is easily administered to individuals who may have sensory deprivation The examiner can administer the questionnaire quickly and efficiently by reading the information to respondents The respondents can also read the information themselves and answer "yes" or "no ". Further rationale for selecting this instrument to ascertain the presence of depression is its reported validity and reliability Yesavage and his associates (1983) reported that the Geriatric Depression Ratin g Scale was more precise than the Beck Depression Scale in distinguishing between depressed and non-depressed persons

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84 The Geriatric Depression Rating Scale was compared to the Zung and Hamilton Rating Scale, and the G D S reliabilities were 0 56 for median correlations between items, 0.36 for mean intercorrelations between items, 0 944 Crohnbach's Alpha coefficient and 0 94 for split half reliability Each of these correlations was higher than the comparable figures for the Hamilton and Zung Scale (Yesavage et al. 1983 : 37-49) "The close relationship between the Hamilton s items and Research Diagnostic Criteria was seen as the factor responsible for the Hamilton s relative success The Fscores ofthe G D.S were 99.48 and 110 .63 for the Hamilton" (Yesavage et al. 1983 : 3749) The G D .S. had a superior trade-off sensitivity (84%) and specificity (95%)" (Yesavage et al. 1983) The Geriatric Depression Scale loses validity, however when the individual is confused Hyer and Blount (1984) report that discriminate validities ofthe G D S with older psychiatric patients indicate the G D S "was more precise than the Beck in distinguishing between depressed and non-depressed patients (1984 : 611-616) Sheikh and his associates (Hyer and Blount 1984 : 165-173) presented the short 15-item version of the G D S and found a score of 5 or above indicates depression Hickie and Snowden (1987 : 51-53) reported that the G D S (Short Form) had a sensitivity of 88% and specificity of 100% Patients also indicated that phrasing of the G D S was easiest. Weiss (1986) stated that no depression scale contains all the criteria characteristic of depression in late life, but the Geriatric Depression Rating Scale has more than any other

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85 Bloch s Ethnic / Cultural Assessment Bloch's Ethnic / Cultural Assessment ( 1983) format was used to obtain information from fifteen respondents selected from the three populations (Appendix IV). This assessment tool measured many elements of the ethnic and cultural variations relevant to the health status of individuals Bloch's Ethnic / Cultural Assessment includes the following categories : Ethnic origin, race, place of birth habits customs beliefs valued behaviors, cultural sanctions and restrictions language healing beliefs and practices nutritional variables, and outside influences This assessment also reviews individual educational status and needs, socioeconomic status, social and family support networks including the ethnic / cultural community The psychological and developmental status was also included The religious influences on the psychological and health/illness of individuals were also evaluated (Appendix IV) The information was collected from selected informants who are representative of the populations living in their communities and participating in activities of daily living Data Collection Seventy-seven persons from the three culturally distinct populations answered the AIDE Questionnaire (Age Illness Depression, Ethnicity Questionnaire, Lamm)

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86 The Geriatric Depression Scale (Short Form, Sheikh and Yesavage 1986) and the illness Questionnaire (Multidimensional Functional Assessment : The OARS Methodology a manual 1979 : 93) Twenty-three respondents are from the Tewa Pueblo population of San lidefonso Santa Clara San Juan Nambe Tesuque and Pojoaque Puebl o s Fiv e of these selected individuals, which represent 20 percent of the respondents provided ethn o graphic information and completed the Bloch Ethnic / Cultural Assessment ( 1983 ) Twenty-five Euro-American indi v iduals provided information for the study by answering t h e G.D S., the OARS illness quest i onnaire, and the AIDE questionnaire. Five of the respondents volunteered and provided ethnographic information Twenty-nine British r espondents answered the questionnaires and five individuals provided data for the Bloch Ethnic / Cultural Assessment. These respondents are representative of a population residing outside of the U nited States Data were collected in each community by the researcher going to the congregate meeting sites and bein g a participant observer. I introduced myself to the participants and they were apprised of the purpose of my presence Directors of the sites gave prior approval and informed the group of my v i sits. Each group and sponsoring agency were informed about the research and gave permission for my visits. After several days of v isiting and often leading group activities I began requesting volunteers to answer questionnaires Participants v iewed me as a health care provider and an individual interested in the well-being of older persons

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87 They often indicated that they viewed me as a visitor and somebody who was educated to help them, I realized that their response to me was as a visitor, although I spent three weeks in each location before I began to collect data Participant Observation in Great Britain I began my v isits to Grantham England in 1982 I developed an educational program for undergraduate students of nursing and social science. The courses developed were Cross-cultural Health Systems and Gerontology Students were American and enrolled at Florida Southern College. Network development followed and I integrated field experiences for the students with health care and social sites for the elderly population This experience led to 12 years of international teaching about culture health and gerontology while building a network of information related to European, British, and American health systems with gerontolo g ical aspects of care provision Members of the health and social service sectors in Great Britain became advisors and mentors for me and the students In 1994, I began to observe the elderly in their communities and collect data related to their physical and mental health. Health care professionals and educators at the Queens Medical Center at the University of Nottingham in Great Britain assisted me in obtaining permission to observe participants and gather data at the congregate site.

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88 Another site selected for this study was the congregate day program at GranthamKesteven Hospital. This facility provides social nutritional programs, social interaction, and health care for the participants. Mentors provided assistance in securing permission to do participant observation and collect information from volunteer respondents Data Collection in Great Britain This research design included administration of questionnaires to 1 0 selected individuals over 55 years of age participating in group activities at the Queens Medical Day Care Center who lived independently Data were also collected at the GranthamKesteven Hospital Nine additional individuals were selected who resided in retirement schemes These individuals live independently and are participants in social activities which are provided at the residences These facilities are provided by the British National Government and the needs of individuals are provided by staff members Congregate dining is also provided for the residents After individuals were selected they were evaluated to ascertain their ability to answer the questions and understand the purpose of the interaction Each individual was apprised of the research and it's purpose as well as informed about the consent form The selected respondent had to communicate an understanding in order for me to proceed with the interview

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89 The AIDE Biographical Data Questionnaire was administered first, in order to collect information about each individual and assess mental functioning. The illness questionnaire was then administered because it required a simple "yes" or no answer. After social interaction with the individuals, I asked if they would like to proceed and answer the Geriatric Depression Scale (Short Form). The fifteen item questionnaire was easily administered and respondents accepted the questions and answered "yes or no" After the administration of the questionnaires the researcher selected indiv i duals for the ethnographic data collection The Bloch Ethnic / Cultural Assessment ( 1983) was administered in order to gather culturally appropriate information Individuals were selected based on their ability to c ommunicate and interact. They were also selected because they were able to live independently and perform activities of daily living. The respondents reported living in Lincolnshire and Notthinghamshire more than 25 years They also spoke English as their primary language The population selected for the study is representative of rural agrarian elderly persons who live in small villages and small cities Some individuals were farmers in this region ofNorthern England which provides milk and dairy products, vegetables and fiuits, as well as rape seed for vegetable oil production Many of the residents of this region were forced into industrialization during World War II and remained living in small cities after the factories became production centers for peacetime commodities Many respondents are residents who relocated to the northern farming areas when they married Twenty-ei g ht of the respondents were born in Great Britain and one in Russia

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90 Participant Observation Among Tewa Pueblo Residents The Tewa speaking persons of San Ildefonso and the neighboring pueblos in New Mexico were selected as a population to study The selection was based on their history of living in pueblos and maintaining their culture rich heritage There are living pueblo peoples who are the direct descendants of those of the archaeological record" (Frisbie 1981 :25) Frisbie (1981 : 25) also states that ethnographic data of the pueblo people may be used to support archaeological inferences The pueblo descendants are those of the Anasazi cultural continuum (Frisbie 1981 ) Contact with the Director of The Senior Center of the San lldefonso Pueblo was made in 1993 I visited the center which is located on the Pueblo adjacent to the Roman Catholic Church and the Head Start Program for children The Director of the Senior Center is a 56 year old woman who is the main informant. She is the individual who became the liaison with the San Ildefonso Tribal government as well as participants of the Senior Center. The major production of the village is the cultivation of crops and grazing animals on the ranches Pottery making is still done by indiv i dual artists while many of the five hundred residents work in a variety of businesses in Los Alamos Espanola and Santa Fe (Eight Northern Indian Pueblo Council 1994 : 30) The Governor of the Eight Northern Indian Pueblos Herman Ogoyo states that the residents have the same heritage and culture that their forefathers preserved for over five-hundred years (ENIPC 1994 : 2).

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91 The eight Northern Indian Pueblos include ; Tesuque Pojoaque Nambe San Ildefonso Santa Clara San Juan Picuris and Taos The Pueblos formed the Eight Northern Pueblos Council (ENIPC) in the 1960 s The Neighborhood Youth Corps and the Eight Northern Pueblos Community Action Program were the first programs developed for the residents The goals of delivering services to community members creating economic enterprises, preserving the lands and fostering appreciation and understanding of the multi-cultural environment of the Pueblos are the goals of the Council. The development of the Senior Center is one of the programs which developed as a result of the joint efforts of the Council and the Federal Older Americans Act which provides funds for nutrition and support services for the elderly I was able to participate for one month on the Pueblos and the Senior Center with the individuals who volunteered to answer the questionnaires. I was also invited to participate in dining, games and visits to other pueblos to see the festivals and meet other family members I was also invited to celebrations during the Holy Day festivals on other Pueblos which provided more interaction with residents

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92 Data Collection Among Tewa Pueblo Residents Permission to be at the Multi-purpose Senior Center of the San Ildefonso Pueblo was secured by the director and I was able to be on the site for four weeks during the period of data collection. The director instructed the partic i pants to answer the questionnaires only if they wished and they did not have to participate I was able to secure information from fifteen of the participants of the center who volunteered answered the questionnaires and were willing to provide ethnographic information All of the respondents are over 55 years of age and speak Tewa and English. A member of the Tribal Council of San Ildefonso gave his life history to me and answered the questionnaires Four other i ndividuals were eager to give life-histories Some of the respondents were eager to have me visit their families and ask family members questions This provided eight more informative subjects I was able to meet a well known family of artisans because their dau g hter is a respondent. She wanted me to meet her parents and see their art works These individuals are responsible for the rebirth of San Ildefonso pottery They provided ethnographic information as well as life histories I was invited to a pottery firing at the San Ildefonso Pueblo The procedure for making pottery is revered by the Pueblo people and it is ceremonial I was able to interact with the pottery-makers as a participant observer.

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93 Six of the respondents are from the Nambe Santa Clara, San Juan, Santa Domingo and Acoma Pueblos Each of the respondents stated they are Tewa people and spoke Tewa and English Three of the individuals also spoke Spanish. They were interviewed after being introduced by friends and families The AIDE questionnaire the Chronic Illness questionnaire and the Geriatric Depression Rating Scale were administered to twenty three individuals Five individuals, two males and three females completed the Bloch Ethnic / Cultural assessment and provided life histories Two respondents are active in pottery making one is a registered nurse and another is an elected member of the Tribal Council and remains employed as a maintenance person at the local high school. One respondent is an 87 year old retired woman who resides alone and has many family memb e rs living at the San lidefonso Pueblo This population was selected because it is representative of elderly Native Americans who reside on a Pueblo This population is invol v ed m arts and crafts production, business and cultivation ofthe crops and ranching (ENIPC 1994 : 30) Participant Observation Among the Euro-Americans in Polk County, Florida I observed individuals at the Multi-Purpose Senior Center in Lakeland Florida Permission was secured from the Polk County Elderly Services which administers the programs for the elderly Individuals participate at the center by choice as well as social and medical referral

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94 The nutritional meals, social interaction, and psychological well being are the basic tenants for referral to the center. Individuals may choose to participate of their own volition The Multi-Purpose senior center provides a lunch meal and daily programs for the participants Some persons drive their automobiles to the center and come with spouses Other persons come to the center on the transportation which is provided by the Department ofElderly Services in Polk County Programs which are provided include lectures of health, nutrition, and other issues There is an arts and crafts center available for the participants The women participate in this area while the men are often segregated playing cards and other games I visited the site for five days during a three week period Group participants are separated by their abilities Those persons who are active and engaged stay in the game and activity areas Participants needing physical assistance are sitting in chairs in the dining area and activities are provided for these individuals Data Collection Among Euro-Americans in Polk County Florida Individuals selected in Polk County are participants at a Multi-purpose Senior Center in Lakeland Florida All respondents are 55 years and older, living independently and actively involved in their community Individuals volunteered to answer the AIDE Questionnaire, the Chronic Illness Questionnaire, and the Geriatric Depression Rating Scale One third ofthe population of respondents are men who ranged in age from 56-93

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95 All individuals were eager to participate and five respondents elected to answer the Bloch/Ethnic Cultural Assessment. Three men and two women gave life histories and were chosen because they were eager to talk about themselves and representative of depressed and non-depressed participants. The individuals chosen to answer the questions were also interested in hearing about each other These participants have many chronic illnesses and wished to discuss their problems The men and women who are respondents lived in Polk County over 25 years The language spoken is English, while only two women spoke other languages as well as English Data Analysis Quantitative analysis of the data collected is done by application of the Statistical Package for the Social Sciences (S P S S 1994 S .Opc). The data analyzed are obtained from the AIDE questionnaire, the Chronic lllness questionnaire, and the Geriatric Depression Rating Scale (Short Form) Anthropac (Borgatti 1992 a) is used to further analyze the scalability of the items on the Geriatric Depression Rating Scale (Short Form) The results are reported in Chapter 5 Qualitative analyses are reported m Chapter 4 Analyses include participant observation and ethnographic information. Ethnographic themes reported are related to the variables selected which are observed to have a relationship with depression in the populations studied

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96 CHAPTER4 ETHNOGRAPHIC LITERATURE OF GROUPS STUDIED Section I-The Ethno-History and Kinship Systems of Three Selected Populations Introduction This Chapter 4 Section I, provides ethno-historical information about each population. Political economic and social patterns are described in order to identify differences which affect the variables selected for study. Kinship is discussed in order to understand the differences related to the social variables of family and relationships to each respondent. The historical development of the areas where the respondents reside also lends insight into the lifeways of the selected individuals who are studied The historical and religious influences of each region also lends further understanding of the customs and rituals which are vital aspects of each community studied Section II o f Chapter 4 is an ethnographic description of responses from selected individuals representing each of the three populations These responses identify themes which are part of the qualitative observations of this study

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97 Participant observations and the answers from the Bloch/Ethnic Cultural Assessment are also discussed The Ethno-History ofThe Native American Population The earliest migrations of the Native American population to North America have been dated about 50,000 years ago (Boxberger 1990 : 2). Since ethnic differences are believed to have originated between 70,000 and 50,000 years ago, the appearance of "Asian traits" correspond with the earliest population movements into the Americas which may also have been during this time span (Shutler 1985:121. Boxberger (1990 : 3-4) explains that the "appearance of humans in the New World" was a journey from Asia to North America that was most likely a continuous process The transition from the PaleoIndian cultural period in North America to the Archaic cultural adaptation is an evolution The transformation of the old hunting culture of the Pleistocene epoch to the varied cultural manifestations ofthe Archaic was a long, gradual process (Boxberger 1990 : 7) The Archaic revolution in life patterns resulted in the creation of permanent settlements with economics which were based upon food production These settlements had increasing populations and more complex technical processes (Boxberger 1990 : 9). The beginning of the Formative period is signaled by the invention of pottery-making (Boxberger 1990 : 9). The development of this complex culture included the appearance of larger population groups, beyond the nuclear family.

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98 The nucleation of populations in urban centers benefited the enlarged community because it facilitated communication and a concentrated labor pool (Boxberger 1990:11 ). The development of cultural complexity also brought forth the development of formalized education and religious systems (White 1949) Cultural complexity is a result of population expansion and growth within a limited geographic area Social and geographic circumscription is a factor involved in the formation of states and more complex social structures (Boxberger 1990 :11 ) The determination of the cultural complexity 1s based upon archaeological evidence and this is not always accurate. Size and scale of communities as well as goods are indicators of the complexity of societies Political and social structure may be determined by identifying social differentiation, access to wealth and resources, and elaborate religious ideology (Boxberger 1990 : 13) Public architecture and symbolic communication such as Indian rock art reveals information of the complexity of the culture This form of record keeping transferred social information as well as events (Boxberger 1 99 0 : 14) Information collected at Chaco Canyon in Arizona indicates the use of architecture for calendric purposes are influences from Mesoamerica. Other evidences have been observed by archaeologists in many different North American locations within a time frame that includes the late Archaic Period and the Formative Period The presence of cultural complexity in North America has been documented back into the second millennium B C at Poverty Point in northeastern Louisiana.

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99 Throughout the ensuing two thousand years the complexity in North America has been documented by the monumental structures, and the figurine sculptures (Boxberger 1990 : 13-14) The elaborate mortuary cults and long -distance trading networks of the Hopewell and Adena cultures and the complex Northwest Coast Mississippian chiefdoms indicate a possible state level of organization in the Chacoan culture of the Southwestern United States (Gibson 1985) The origins of the Tewa speaking people of the Pueblos of New Mexico are described by Willey ( 1966 : 181-182) as a Southwestern tradition of those sedentary cultures derived from a Cochise base with the introduction of cultigens and ceramics from Mesoamerican (Lucius 1981:53) The Anasazi were defined as having developed from an Archaic base with the additions of pitstructures ceramics, and cultigens from the already developed Mogollon Tradition (Jennings 1981:298) Lucius (1981 :53) further proposes that the Anasazi Tradition may have resulted from the adaptation of Mogollon homesteaders to a frontier situation Frisbie (1981:26-27) says that a shift to a horticultural strategy began in the highland valley region of central Mexico and gradually pushed into the northern frontier area including the Southwestern United States The Anasazi culture changes are described as moving through a continuum from hunter-gatherin g to horticulture The major power intervention was the arrival of the Spanish The Athabascan, Spanish, Mexicans, and Americans continue to be part of the living cultures of the southwe st.

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100 The Spanish culture is part of the culture in the secluded enclaves of Northern New Mexico (Frisbie 1981 : 26) At the time of the Spanish contact the Pueblos were reported to be egalitarian, autonomous units. Adams (1981:324) reports there may have been "a more powerful central authority in the fifteenth century" at Hopi because of the population concentration (Frisbie 1981 : 26) The greatest complexity in the community was during the Pueblo IV period when larger communities developed Frisbie (1981 : 28) and Cordell (1976) state that the highest level of attainment of the Anasazi culture occurred during the Chaco Phenomenon between 970-1120 A.D (Frisbie 1981:28) This included Sociocultural integration which is synonymous with the chiefdoms or ranked society (Frisbie 1981 : 216) Snow ( 1981:3 55) states that "society is based, in part on a status and role hierarchy among community members whose activities, responsibilities and interactions are intricately balanced between alternating agricultural and non-agricultural phases of the annual subsistence and ritual cycles. Access to successive status roles is provided by formal rituals of passage through life into death" During the Pueblo IV period which was from 100 A.D to 1540 A.D., the system was disrupted following the Spanish invasion and subjugation of the people (Frisbie 1981 : 26) During this period the Pueblo people were forced into rnissionization by the Spanish soldiers and priests. The Tewa represented one of the largest language groups in the Southwest Rio Grande region at the time of the first Spanish expedition in 1540 The first census report ofthe Tewa population reported 10,000 persons in 1634

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101 The pueblo villages of the Tanoan linguistic group extended southward from Taos, New Mexico to the present site of El Paso, Texas The Tewa speaking people are part of the Tanoan linguistic group The San lldefonso Pueblo is part of the surviving villages The people of the pueblos of Tesuque, Nambe, San Ildefonso, Santa Clara, and San Juan cany many ofthe traditional cultural and social characteristics ofthe Tewa (Dozier 1967 : 3) Dozier (1967 : 4-5) reports on an expedit i on by Antonio de Espejo in 1582 and states that this account of the villages and life-ways of the Pueblos could be a description of the way of life at the beginning of the twentieth century The following is a description by de Espejo (in Dozier 1967:4-5) "As we were going through this province (the Piro country), from each pueblo the people came out to receive us, taking us to their pueblos and giving us a great quantity of turkeys, maize beans, tortillas and other kinds of bread ... They g rind on very large stones Five or six women to g ether grind raw corn ... and from this flour they make many kinds of bread They ha v e houses of two three, and four stories with many rooms in each house ... in each plaza of the towns they have two estufas (kivas), which are houses built under g round very well sheltered and closed with seas of stone against the walls to sit on Likewise, they have at the door of each estufa a ladder on which to descend, a great quantity of community wood that strangers may gather there In this province some of the natives wear cotton, cow hides (buffalo) and dressed deerskin ... the women wear cotton skirts, many of th e m being embroidered with colored thread and on top a manta like those worn by the Mexican Indians tied around the waist with a cloth like an embroidered towel with a tassel...and all, men as well as women, dress their feet in shoes and boots, the soles being of cowhide and the uppers of dressed deerskin The women wear their hair carefully combed and nicely kept in place by the molds that they wear on their heads one on each side, on which the hair is arranged very neatly though they wear no headdress

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102 In each pueblo the cacique's orders ... and when the Spaniards ask the caciques of the pueblos for anything, they call the tequitatos who cry it through the pueblo in a loud voice ... In each one of these pueblos they have a house to which they carry food for the devil, and they have small stone idols which they worship Just as the Spaniards have crosses along the roads, they have between the pueblos in the middle of the road, small caves or grottoes, like shrines, built of stones where they place painted sticks and feathers saying that the devil goes there to rest and speak with them They have fields of maize beans, gourds and piciete (tobacco) in large quantities ... some of the fields are under irrigation, possessing very good diverting ditches while others are dependent upon the weather. Each one has in his field a canopy of dour stakes ... where he takes his siesta for ordinarily they are in their fields from morning until night. . their arms consist of bows and arrows macanas and chimales; the arrows have fire-hardened shafts, the heads being pointed flint, with which they easily pass through a coat of mail The chimales are made of cowhide like leather shields; and the macanas consist of rods half a vara long with thick heads With them they defend themselves within their houses It was not learned that they were at war with any other province." (Dozier 1967) During the first years of colonization of the Pueblos the Spanish built many building which were large and walled compounds within or just outside the Pueblo villages (Dozier 1967:6). Indians were workers and servants and employed at leatherwork, weaving black smithing and cooks The religious responsibilities of the missionaries consisted of saying Mass conducting burial services, performing baptisms and marriages, and conducting vesper services The Indians were taught the prayers and they were also responsible for making the villages attend church services (Dozier 1967:6).

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103 The missionaries also forced the eradication of Pueblo customs and beliefs Kivas were raided and masks and prayer sticks were burned The religious leaders were whipped and hanged as witches when their activities which were underground became known to the missionaries (Dozier 1967 : 7). This dominance of the Pueblos by the Spanish missionaries and colonial officials brought exploitation which created hatred and revolution In 1680 the Pueblos successfully carried out a revolt under the leadership of the San Juan Tewa Indian, Pope at the Taos Pueblo (Dozier 1967 : 9) Although this uprising only lasted about three weeks, 2 ,000 settlers had been driven out and 347 Southern Tewa were killed (Dozier 1967 : 9) Dozier (1967) relates that "the effect of the Spanish indoctrination on the values and beliefs of the Pueblo Indians appears to be negligible" (1967 : 12) This author quotes John C Bourke who reports that "the Pueblos cling to their ancient rites and became hypocrites not Catholics, who remain until today, Pagan and Anti-Christian" (Dozier 1967 : 12) This contact with the Spaniards brought permanent changes to the Pueblos A Catholic chapel became a feature of the community The center of the community was the ceremonial Kiva This continues to be the hub of social and ceremonial life in the Pueblo (Dozier 1967 : 10-12). The New Mexico Tewa kinship system is one of bilateral generational type (Dozier 1967 : 242-257) Siblings and mother's sisters are distinguished on the basis of their seniority The New Mexico Tewa are called by clan terms regardless of clan affiliation

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104 Ortiz ( 1969 : 121-146) discusses the issues of dual organization The "Tewa myth of origin represents a charter for T ewa social and ritual life" (Ortiz 1969 : 121). He defines six categories into which the T ewa classify all existence. Each of these categories are divided into two parts, according to the moieties and they comprise three linked pairs. At death the soul of each human category becomes a spirit of its linked supernatural category There are six rites of passage which each T ewa normall y undergoes from birth until death (Ortiz 1969 : 122) The naming rite is the first ritual which is performed four days after birth when the passage of the child into society as a whole is emphasized The natural and supernatural categories are demonstrated at this time During the first year of life another rite of passage called water giving is held and at the time the child begins the process of recruitment into the moiety of the father (Ortiz 1969 : 122) Between the ages of six and thirteen two other rituals of recruitment are held The first rite claims the child for the moiety, while the second which is water pouring recognizes the individual sexually by giving sex-specific duties and responsibilities (Ortiz 1969 : 123) This rite of passage brings the child into the adult world and the young Tewa is recognized as an adult member of the moiety The fourth rite allows transfer from one moiety to another. The transfer can occur by repeating the entire three-stage process into the opposite moiety (Ortiz 1969 : 123) The fifth rite of passage is marriage If the bride is of the opposite moiety of her husband, she must undergo the three rites of recruitment into her husband's moiety

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105 Death is the sixth and final rite of passage which is called releasing This rite emphasizes the solidarity of the whole society by clearly drawing the line between all of the living and the dead (Ortiz 1969 : 123) The Tewa answer at the time of the most important life crises is that the society is emphasized above the moiety The soul passes from the whole society not the moiety The soul goes to join its ancestors at one of the four directional shrines which surround the village and offerings of food are taken there by the survivors (Ortiz 1969 : 124) Ortiz ( 1969 : 128) presents the Tewa VIew of existence as constituting a hexamerous structure. The d i vision of the entire spiritual and human world is into six categories which permeate the circular village, reaches the distant sacred mountains, hills and shrines the home, and the T ewa mind itself The Tewa have dual organization and unlike most societies with dual organization, Tewa social structure did not disintegrate upon contact with European culture. They have become the most enduring primitive societies in the world while sustaining severe pressures toward change (Ortiz 1969 : 132) The Tewa provide a dynamic and flexible response to the challenges presented by their rigorous dualism They do this without sacrificing the essential integrity of the dual organizations (Ortiz 1969 : 134) The dynamic and flexible Tewa dual organization is best illustrated by events that took place in the Tewa Pueblo of San lldefonso (Whitman 1947) The people of San Ildefonso regarded the dual organization as the only way they could operate meaningfully in social relations and the only way they could have order in their world

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106 The Winter moiety was reduced to two families Therefore, they could not operate on the basis of the traditional Winter and Summer moieties (Ortiz 1969 : 135) They divided their Summer moiety into a south and north division, based upon residence, and the north side absorbed the two Winter families The San lldefonso are still attempting to sort out the many problems which are necessitated by this change (Ortiz 1969:135) All T ewa are baptized, confirmed, and receive their first holy communion, but these are parallel rites which exist independently of water giving and other early life rites (Ortiz 1969: 14 7) "Religious responsibility is overwhelmingly in the hands of the men and participation in rituals tends to run along family lines" (Ortiz 1969 : 150) A man who does not have at least one son to participate with him in religious ceremonies is considered a weak man When the Tewa dead are buried in the consecrated Catholic Church cemetery, the T ewa still persist in the more ancient belief that the dead are really at the shrines surrounding the village (Ortiz 1969 : 152) In a ritual ceremony, the chief of the Summer moiety hosted a feast on Good Friday every year. During the feast, the lights went out and the food disappeared He told the guests that the spirits had come and taken the food This was his way to compete with the Catholic Church during the intensified ritual of Easter. Ortiz (1969: 152) reinforces the observation that Tewa rituals are integrated with Roman Catholic rites.

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107 Marriage is a ritual which has caused considerable conflict between the Tewa practices and Roman Catholicism (Ortiz 1969 : 153) The Catholic church has never been able to tolerate dissent in life crisis rituals but the church is particularly non sanctioning of the T ewa practices of marriage. Cross-cousin marriages are not tolerated by the Catholic Church because of the rules of exogamy The Church also does not sanction any elaborate reciprocal services and rituals of death which are frequently associated with the Tewa dual organizations (Ortiz 1969 : 15 3) Medicine in the Pueblo culture in the American Southwest is related to kiva ceremonial rituals (Harner 1990 : 27) The sipapu is a hole which is located in the circular kiva which is an entrance into the Underworld (Popov 1968 : 138-139) It is thought that the shamans of the medicine societies used the holes to enter the Lower World when in trance (Harner 1990 : 27) Medicine Society work is highly secret among the Puebloan peoples (Harner 1990 : 28) The Tsave Yoh ofthe Tewa are known only in sacred traditions They are thought to inhabit the labyrinths of the four sacred hills and are fundamentally rooted in these traditions (Ortiz 1969 : 159) The Tsave Yoh perform a therapeutic function During their visits to various homes, the sick are brought out so the Tsave Y oh may minister to them The patient receives four light strokes with the whip on his afilicted area. Then the Tsave Y oh takes a small portion of spruce from his collar and gives it to the senior woman of the household She is asked to chew this along with cornmeal, and spit the solution on the patients afflicted area for four days. This therapeutic function serves to distinguish the Tsave Yoh from other deities

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108 The Tewa shamans are respected and renowned for their successful healing practices, and Indians curing receives a major emphasis in their ceremonial ritual (Dozier 1967 : 78) The New Mexico Tewa have a reticent characteristic of personality (Dozier 1967) The world view of the Tewa is the premise that "man and the universe are in a kind of balance and that all things are interrelated" (Dozier 1967:97) There is no dichotomy between good and bad only a disturbance in the equilibrium which exists between man and the universe (Dozier 1967 : 81) The activity world and the ethereal world of the Tewa are all believed to be in a state of balance The activity world is one of cooperative helpfulness with everyone working for the good of the whole (Dozier 1967 : 81) When bad things occur, the Pueblo Indian's belief is not one of punishment by a supreme being but rather a break in the interrelatedness of the universe (Dozier 1967 : 81). Man must use food and material resources sparingly and they must reciprocate by appropriate propitiatory rites (Dozier 1967 : 82). The ceremonies of propitiatory rites are important because they affect well-being and bring much needed moisture to the parched lands (Haeberlin 1916) "The assertion is made by the Pueblos 'It will rain; we are happy; it will rain; we are dancing ; we are dancing; it will rain'. Cause and effect are hardly differentiated. Let us hope all people are happy, but let us make sure that they are dancing" (Aitken 1930)

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109 The Tewa of San Ildefonso The ancestral homes of the San lidefonso are the cliff dwellings of Mesa Verde The Tewa speaking people occupied the Pajarito plateau before they located at the site of the present pueblo They have inhabited this area from about 1300 A.D The village which was visited by the Spanish in 1598 was located one mile from the present pueblo (Bahti 1989 : 25) The people of the village moved to the top of Black Mesa after the Rebellion of 1680 After nine months they returned to their village They again revolted against the Spanish authority in 1696 and sought refuge among other tribes and moved as far west as the Hopi village and settled Hano The Spanish resettled San lidefonso with other Tewa speaking people in 1702 (Bahti 1989 : 25) Half of the population of San lidefonso was wiped out with a smallpox epidemic in the late 1700's Religious suppression continued and several witchcraft trials were held at this pueblo (Bahti 1989 : 25) Maria Martinez and her husband Julian with other family members began to revive the making of black polished pottery This pottery and it's artistic designs became well known and economic rewards followed During the following fifty years the pueblo began to heal their religious and secular factionalism and develop community leadership (Bahti 1989 : 25)

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110 The San Ildefonso Pueblo has a population of 675 and 300 residences (Bahti 1989:25). They speak Tewa, Spanish and English and their native name is Pokwoge which means "where the water cuts down through" The Pueblo is located on the Rio Grande River in Northern New Mexico Ortiz (1969 : 156) believes that the entire literature of the Spanish-Indian acculturation in the Pueblos should be reviewed. The interplay of ideas and symbols need to be studied so new light can be shed on many aspects of the merging of two cultures The Ethno-History of the British Population of the Midlands The United Kingdom (U. K.) Is a democratic monarchy which consists of four ( 4) countries which are Wales, England, Scotland, and Northern Ireland (Bennison and Fry 1986 : 211). This country has strong ancient historical roots which have been integrated into the present. The great British Empire of the 19th century has become a loose British Commonwealth of nations which are independent (Bennison and Fry 1986 : 211) During the past twenty-five yeas there has been a mass immigration from the Commonwealth nations in the West Indies Asia, and Africa (Bennison and Fry 1986 : 211) The U.K. is a densely populated small country with a population of 56 6 million persons During the second half of the 19th century the industrial revolution produced mass migration to grimy cities (Bennison and Fry 1986 : 212).

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111 The population is eighty percent white with a changing percentage of persons of color because of immigration Eighty-five percent of the population declare Anglican Episcopal as their religion which is the Church of England Only ten percent of the population participates in religious worship There are four million Catholics, 400,000 Jews and an increasing number ofMuslims (Pettifore 1994) This is socially liberal country with a strong democratic leadership Forty percent of the children are born outside of legal marriage Abortion, homosexuality, and prostitution are legal There is an established governmental provision for health care, welfare, and education for all of the citizens of the United Kingdom (Pettifore 1994) The population of the South Kesteven district of Lincolnshire numbers 103,000 persons (Bennison and Fry 1986). This district i s located in the North Central region of England with an area of364 square miles This area is described as rural England with the finest Georgian stone towns It is the most rapidly developing part of the now fashionable Lincolnshire (South Kesteven-Linco l nshire 1993 : 15) It is 75 miles north of London on the A-1 road which is the main road to Lincoln, York, and Edinburgh Grantham is the city in which one half of the respondents live This city was a prosperous town in the middle-ages King Edward IV gave the town i ts first charter and in 1643 it was captured by Cromwell from the Royalists (South Kesteven-Lincolnshire 1993 :26) The town was connected to Nottingham by a canal which was used until the 19th century Coaches through Grantham in the 18th century provided traffic and famous inns were established The Great Northern Railway system developed in the 19th century which brought prosperity to the town (South Kesteven-Lincolnshire 1993 :26)

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112 The following is a description of Grantham in the middle ages : "the town shows no vestige of fortification; yet it appears to have been walled and to have had a castle ; and hence it retains for four principal streets, the names are Castle-gate, West-gate, Water-gate, and Wine-gate The streets are well paved and clean Ancient architectural features are, not very long ago numerous enough to give artistic and historic interest to the town's appearance ; but they have in large degree been swept away by modem improvement. A commandry of Knights Templars with some grotesque carvings of cherubs and allegorical figures was converted into the Angel Inn" (Gazetter in South Kesteven-Lincolnshire 1993:26) The midlands regiOn of England is a beautiful rolling countryside with small villages nestled along the roads. Each village has some old dwellings which are connected There are new homes which are of a modem architectural style built alongside these old dwellings. Each village has an Episcopal church which usually dates back to the sixteenth century Each village has a local pub or two which is open for lunch and dinner and closes at mid-night. Dart areas of game are part of the activities of the pubs Stone houses and walls are visible in the Midland area St. Wolfram is one of the most beautiful churches in England which dates to the 14th century The tower and spire are landmarks in this beautiful green countryside The Church's original building is Saxon with six of the nave pillars which are Norman The nave and the north aisle are from the 13th century (South Kesteven-Lincolnshire 1993 : 27) Grantham has a regional hospital which provides in patient and out-patient services It is part of a regional health authority which provides health services for the people

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113 There is a College of Further Education which has Business Studies, Engineering and General Studies with 3 000 students enrolled There are many secondary and grammar schools as well as the King's School for Boys which was founded in the 16th century (South Kesteven-Lincolnshire 1993 :29). Grantham is a Market town where the Saturday general market is held for the farmers to bring their produce to the residents of Grantham. The rape flower is grown in the countryside and cows graze for milk production. Other vegetables are grown for national distribution and consumption Stilton cheese production is an agribusiness in this region and the neighboring town of Melton Mowbrey is the production and distribution center Sir Isaac Newton was born in 1642 in the nearby village of Woolsthorpe by Costerworth and he graduated from the Grantham Grammar School and then continued his education at Cambridge University. Margaret Thatcher who is the first woman Prime Minister was also born and educated in Grantham (South Kesteven-Lincolnshire 1993 : 26) Nottinghamshire is a district where the remaining respondents reside. This area is rich in the traditions of history literature, and legend The area has pasture lands which are defined by hedgerows (Frank 1985:207) The beauty ofthe hillsides are endowed with the grazing cows and the cottages The countryside is also laden with thousands of grazing sheep. Nottingham castle was built as a fortress by William the Conqueror in 1068 and destroyed during the Civil War and was transformed into a museum in the 19th century This area gave rise to the legends of Robin Hood (Frank 1985 : 207).

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114 Ye Olde Trip to Jerusalem Inn is located at the castle hill and dates back to the crusades. It is a dark cavern which has the smells and signs of a centuries old land-mark. The Queens Medical Center is located in Nottingham and provides complete inpatient and out-patient services for the region There is a medical college and district nursing school co-located in the facility. The center has complete support systems for all persons in the area and specialized services for persons throughout Great Britain. The Prince of Wales had orthopedic surgery in this center (Kirkland 1992: 1). This facility houses the congregate meal site for the elderly who participated in the research This area has a great deal of agriculture, but the Industrial Revolution created a city with strands, railway stations, theatres, and many motorways (Frank 1985:207). The population of this region is representative of individuals who were born here and others who migrated during World War II. This area provided factories for production of war supplies and after the war factories converted to civilian manufacturing. During the lifetime of the respondents, they witnessed the results of the Age of Rationalism and a Scientific Renaissance in Europe (Ferguson and Bruun 1947:779). In the beginning of the 19th century farming was done in the same manner as 2, 000 years before. After 1870 an acceleration of forces began shaping modern life (Ferguson and Bruun 1947:785). Inventions and discoveries began a Technological Revolution which fueled the development of factories and towns which grew up in their environs. Until this period the people of Britain lived chiefly on the land and supported themselves and their families in agricultural labor (Ferguson and Bruun 1947:785).

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115 "Kinship, friendship and local community are relational contexts which provide support and care and which delimit other kinds of resources and power for men and women and for different generations ( d' Argernir in Goddard Llobera and Shore 1994 : 218) d'Argernir (1994 : 218) states that among these relationships, relatives have the most important role in European relationships Kinship is therefore the arena where individuals try to solve problems generated by specific social processes It is in this context that we understand the value of family and its ability to be flexible and multifunctional Kinship is also a way to establish reciprocities which help support individuals (d'Argernir 1994 : 218) Dependency and the need for support and care for individuals tends to increase with aging populations Dependence on the family increases as funding for social support decreases in Europe (d'Argernir 1994 : 220). Western Europe has a bilateral kinship system (Bott 1971b : 116) Kinship consists of persons who have a relative in common, whether it is traced through men or women (Bott 1971 b : 117) All kinship systems are bilateral because individuals have personal networks of relationships with both paternal and maternal kin (Radcliffe-Brown 1929) The major difference between bilateral kin s y stems in small-scale societies and industrialized societies is the right to land and other resources (Bott 1971b : 118) In the industrialized societies individuals may be mobile physically and occupationally thus may be separated both geographically and socially (Bott 1971b : 118)

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116 British kinship makes a distinction between consanguinity and affinity Blood relatives have specific titles whereas relatives by marriage are called "in laws" (Segalen 1988:45) There are relatives in nature who share heredity and those ofthe order of law Relatives of the order of law often are bound by law or custom conduct and behavior (Segalen 1988:46). Filiation implies the recognition of links between individuals arising from the fact that some are offsprings of others (Segalen 1988:46) Direct line is one which runs from parents while collateral lines are those which are cousins who share a common ancestry. In industrialized societies the concept of filiation is present, but social groups are formed less on kinship and more on the basis of age groups, social class, friendship, work, and leisure (Segalen 1988 : 47) There are many conflicting views of industrial development and the effects upon the family (Thompson 1963:416 ; Parsons 1965:96 ; Segalen 1988 : 75) Segalen (1988:75) reports that several studies emphasize the active role played by the family in migratory processes when the pressures of continuity stability, and a new environment caused problems The nuclear domestic group is now the prevalent form of the family unit (Parsons 1965) The family has become the protection for the conflict ridden inhuman modern society While the influences of kinship and the family have decreased the responsibilities of supporting the members have increased (Segalen 1988:80)

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117 Providing emotional support, raising children, and sexual satisfaction are major burdens placed upon the nuclear family and they also include providing the for domestic groups of older generations (Segalen 1988:81). Kinship serves as an identity and it offers access to the community. Kinship networks give a feeling of stability and belonging, even when families are separated and individuals live away in isolation (Segalen 1988:93). In a major study of British individuals in East London who were rehoused in the suburb of Greenleigh, major changes occurred. Contact with the mother became less frequent because the distance to travel increased. Individuals depended more on their marital relationship, status was replaced by networks of mutual acquaintances, and individuals were not identified as part of a kinship group and a part of collective patrimony (Segalen 1988:93). Bott (1971:296) reports that the importance of the kin network is its density and relative permanence. Relationships with close kin often survive even over great distances. Kinship and friendship are most important types of primary relationships. The changes in society in England during the twentieth century have affected individuals and families. Social mobility is necessary in a changing society which demands new knowledge and qualifications. The family is the agent of a phenomenon that changes, is mobile, and melts into the dynamics of the whole social body (Segalen 1988:298).

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118 The Ethno-History and Kinship System ofPolk County Residents Polk County is located in the center of the state of Florida. It has gently rolling hills with many lakes and citrus groves. This area was a thriving Indian settlement until the Indian Wars of 1836 when Andrew Jackson's army forced the Indians into the Florida Everglades to escape being transplanted to Oklahoma (Brownell 1989). American Indian artifacts dating back to 1500 B C.E. have been uncovered in the Lake Hollingsworth area of Lakeland. It is thought that both Carib and Seminole Indians were in this area (Santosuosso 1993:1 ). Euro-American settlers began to arrive in the 1850's. John Henry Hollingsworth and his family built a home on the south shore of Lake Hollingsworth. They left this home but by the 1870's and 1880's development began to increase significantly (Hetherington 1928:85-86). In 1881, Abraham G Munn, a wealthy manufacturer from Louisville, Kentucky bought several thousand acres of land in Florida and incorporated a tract now called Lakeland (Hetherington 1928:88) During the same period of time an English settlement was developed two miles east of Lakeland. Younger sons of prominent British families came seeking fortune and adventure and they were called "remittance men" (Hetherington 1928:89). This area and the settlers later became part of the developing town ofLakeland (Hetherington 1928 : 89).

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119 In 1885 the railroad came to Polk County and settlers came from Alabama and Georgia to plant and grow oranges in Lakeland (Hetherington 1928 : 90) The area soon became the center of citrus production and mansions were built on Lake Hollingsworth. Park Trammel lived here and he became governor of Florida and a United States Senator (Santosuosso 1993:2 -3). Citrus production became an important agricultural interest when transportation for the products was facilitated by rail and roads (Hetherington 1928 : 180). During the early part of the twentieth century a road from St. Petersburg to Polk county was built. Florida Southern College relocated to Lakeland in 1922 Shortly thereafter several hundred acres of land were developed into a golf course and a considerable number of fine homes were built (Santosuosso 1993:4). The Lakeland Yacht and Country Club was built in 1929 At this time the city of Lakeland was slowly developing into a community with a population of 16,500 and continued to be a tourist destination (Brownell 1989 :3). During the 1930's and continuing through the early 1950 's, Frank Lloyd Wright designed and supervised the building of structures for the campus of Florida Southern College (Santosuosso 1993:5). This remains the largest collection of Wright architecture in the world. Polk County is the largest county in land area in the state of Florida (Brownell 1989 : 6). It has a population of 395,000 residents who represent immigrants and individuals born in the county (Lakeland Economic Development Council 1996)

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120 Recent development in the northern area of Polk County has increased the immigration of individuals from the states in the northern and mid-Atlantic geographical regions (Lakeland Economic Development Council 1996 ; U.S Postal Service Division 1996 : 111). The county has been shifting from a rural-agrarian region to several urbanized centers since 1975 The phosphate industry, citrus production, and cattle raising were the major industries during the 1950's to the 1970's The world change in phosphate demand caused major industry changes which resulted in massive labor reductions between 1977 and 1990 The unemployment rate was 19 percent in 1981. Agricultural shifts have occurred because of the freezes which destroyed thousands of acres of citrus. The citrus industry has maintained production, but the growing of fruit has been moved to Southern Polk County and other more southernly regions of Florida The availability of relatively inexpensive land has created a market for homebuilding This industry has been growing since the mid 1980's (Lakeland Economic Development Council 1996) This area is also a l ocation which is hospitable for mobile home communities which have proliferated These changes in the region have created a multi-cultural environment. Immigration to this area resulted in a population of various ethnic and religious backgrounds Cultural variation is evident and the aging population reflects the accommodation to change

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121 Early religious observances in Polk County were done at camp meetings. Each small community grew to a point where a Methodist and Baptist church was built A Presbyterian church was formed in Bartow in 1882 An Episcopal congregation was formed and held their first service in 1888 (Hetherington 1928 : 172-173). The dominant religions of the area Protestant and Catholic There are two Jewish Congregations and one Unitarian Universalist Congregation. Of the Protestant religions, the Baptists constitute the majority, while the Assemblies of God have one of the single largest congregations which is 6 500 persons (The Lakeland Ledger 1995a) The fastest growing Christian denomination is the Catholic Church which has added four new churches since 1980 In-migration brought many more Catholics to the once Protestant region of central Florida. Polk County has one of the largest collections of houses of worship in the country in relation to the population It remains a center for conservative values influenced by religious affiliations. Polk County has five colleges and universities which have influenced the development of education and services in the region The high school graduation rates remain low at 66% percent. The unskilled labor pool has created a market for the service industry There are small minority populations, Black, Hispanic Asian, and an extremely small number of Native Americans with no Reservation in Polk County (The Lakeland Economic Development Council 1996) There are 84.2% White persons 13.4% African-Americans, 4 1% Hispanic, 0.85% Asians, and 0 5% Native-Americans (U .S. Postal Service Lakeland Division 1995 : 4)

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122 Polk County grew as did the rest of Florida from 1960 to 1980 The growth and transition was slower than the coastal regions which reported a new family every four to six minutes (Cobb 1984 : 140) Children who were raised in Florida were called "hillbillies" by their new northern classmates In middle-age, they referred to their new associates as "Yankees" (Cobb 1984 : 54) In-migration of Engineers and technically educated individuals was evident in Florida during the 1960's The aerospace industry brought many individuals to the newly growing areas Individuals who were born in the region were trained in skilled jobs in vocational-technical schools (Cobb 1984 : 1 05) In Polk County, the engineers came during the 1960's to provide technical knowledge to the rapidly expanding phosphate industry. The local population was hired as laborers to "work the mines" and earned salaries which were usually double the hourly wages in other industries The citrus industry began to produce juice and fruit products for consumption all over the world It hired unskilled laborers as fruit sectioners "during the season" These seasonal laborers had no benefits and often remained unemployed during the summer season Grove laborers who were born Polk County were slowly replaced by migratory Hispanic labor during the 1960's and 1970's (Harris and Allen 1978) A "Cracker" is the name for a cowboy or cattle owner in Florida (Hetherington 1928 : 184) The cattle industry remains an agricultural force in Southern Polk County which encompasses huge ranches with thousands of head of cattle These ranches hire local individuals who have land management skills and who have experience working with the livestock.

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123 Tourism is rapidly becoming a maJor economic force in Polk County. This industry provides many service related jobs which induces in-migration to the region The area has developed as a retirement center because of the lower cost of living as well as the familiarity with the region by seniors who travel to Florida. The largest employer in Polk County is the Publix supermarket chain. It is the home center for this chain and the founder of Publix remained in Lakeland until his death in 1996. Many individuals have been employed a lifetime by the Publix corporation and they have prospered and given generously to the community. Lakeland Regional Medical Center is the second largest employer in Polk County which employees 2,500 persons. There are over 700 physicians in Polk County and it is a regional medical referral center. The kinship system of the United States does not provide the basic framework of the total social structure for individuals and families (Bott 197lb : 116) A bilateral kinship system is evident in Polk County Persons are affiliated in the same way with both their mother's and their father's relatives Children relate to both their father and mother with the same social affiliation Individuals often rely on the legal system to provide distribution of inheritance and direct life decisions The population of Polk County is representative of many other areas in Florida where the elderly reside They are geographically located at a distance from their children. Although geographic proximity is not a determining factor in the frequency of childrenparent contacts it is certainly a contributing factor (Segalen 1988 : 82)

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124 The literature on American families and kinship indicates that between fifty-one and eighty-four percent of older individuals live within one hour's travel from their adult children (Troll et al. 1979; Frankel and DeWit 1989; Shanas 1977; Segalen 1988; Atchley 1994). The number of children older persons have is an important factor in adult childparent relationships (Atchley 1994). The more children an individual has increases the contact with them and the more likely the elders will receive support and aid (Hoyert and Seltzer 1991 ) The lifeways of individuals in Polk County are representative of the dominant culture of the United States Cobb (1984 : 164) reveals that the historical circumstances that shaped the destiny of the agrarian South played a major role in forging the character of an industrial South The Sunbelt South reflects the "influences of a complex heritage, a heritage whose best elements had recently become as difficult to preserve as its worst has been to overcome" (Cobb 1984 : 164) Section II-The Results ofEthnographic Information The respondents provided a great deal of information related to the variables in the study The questionnaires provided data which are analyzed for statistical study Each individual who provided ethnographic information also answered the AIDE (Age Illness, Depression, Ethnicity, Lamm 1989) questionnaire The Geriatric Depression Scale (Sheikh and Yesavage 1986, Short Form) and the Chronic Illness Inventory (1975 O A.R S Methodology)

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125 The informants who provided more detailed ethnographic information responded to categories ofBloch's Ethnic/Cultural Assessment (1983) Ethnographic Description and Themes of The Native American Population The Native Americans selected for the Bloch Ethnic / Cultural Assessment provide important information related to the presence of chronic illnesses Each of the respondents indicate they have many illnesses but each accepts his/her ailments. The acceptance of the illnesses includes feelings of being treated well and not being helpless One individual with sensory deprivation exhibited the most hopelessness but continues to participate in pottery making and teaching and is not depressed Each of the individuals also is very involved with activities The potters continue to be productive and teach others their art, while another is a volunteer in the senior center. Each of the respondents sees children and grandchildren with a spouse and sees friends daily The following interviews demonstrate the continuum of interaction of this population with the community where they reside

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126 Ethnographic Description ofNative Americans Population Interview with Respondent # 1 An 80 year old respondent is friendly and wants to participate in talking with me. His wife is present and very quiet and non-responsive This respondent participates in the congregate dining program and talks with many of the other participants. He is greeted by both men and women and takes his seat at a table which is predominantly occupied by male participants. He states the he grew up in Texas, came to New Mexico after the war and married his wife He was born in Macon, Georgia and is Cherokee Native American His wife is a native of Sal Ildefonso and is Tewa He went to school in Texas and completed the twelfth grade in a "non-Indian school". "My wife went to the Indian School in New Mexico" When he moved to New Mexico and married her, he joined his wife's family at San Ildefonso and speaks Tewa. He is retired for the past 20 years after working thirty years in Los Alamos for the United States Government at the laboratory They moved back to the Pueblo of San Ildefonso when he retired When asked, "Do you do anything related to your work at the present time"? His answer was "Yes I keep busy all of the time". He and his wife live together and have eight adult children. Two children are deceased

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127 They have fourteen grandchildren and visit with some of them daily and others who live in Santa Fe weekly. He visits with friends daily both at the congregate site and the Pueblo When the respondent was asked questions about illnesses from the OARS (1975 Multidimensional Functional Assessment: The OARS Methodology) he responded in the following way A. "I have had a coronary bypass surgery and (It) has been doing well I have cardiac and blood pressure and problems, but it is under control." He reports a little problem with vision He has circulation problems with his legs "I have Bells Palsy but it just affects the side of my face recently I go to the clinic in Santa Fe" He wears a patch over his eye which has been affected by the Palsy and has residual left sided facial paralysis "This doesn't dampen my spirits When he responded to the Geriatric Depression Scale questions he expanded the simple yes and no responses in the following way A. When asked if he was basically satisfied with his life he stated "I'm still alive When asked if he got bored, he stated "I chop wood He answered "You bet your life" when asked if it is wonderful to be alive now When asked "Do you feel that your situation is hopeless?" he responded "you get old, nothing you can do" Although he is reality oriented to issues related to age and illness, he scored four on the Geriatric Depression Scale and Short Form (Sheikh and Yesavage 1986), which indicates he is not depressed.

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128 While he reported five chronic illnesses, which is above the mean of 2.5 in the Native American population, this respondent has a positive attitude and remains active and involved in his community Interview With Respondents #2 and #3. I was introduced to this couple by their daughter who is a participant at the congregate dining site She stated that her parents would like to meet me and that they are very interesting since they are artist potters and quite elderly Viola is fifty-six years old and is a Registered Nurse who works with new born infants at this time. She is also a respondent in the study. We walked along the road from the congregate dining site in front of the Kiva and Catholic Church to a row of brown adobe houses which comprise the San lldefonso Pueblo Viola knocked on the door and called a Tewa greeting. She welcomed me to this entry room which was a storage area before entering a large kitchen area We sat down around the table and I was introduced to her mother who is an 85 year old Tewa woman She was fiiendly and offered me a beverage. She called to her husband, whom she said "was sleeping in the parlor". An elderly man with visual difficulties entered the kitchen and warmly greeted his daughter and me Viola asked them if they were interested in answering questions about their health and life history. They both said they were very interested in doing so They wished to show me their art work and talk about how they continue the pottery making.

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129 Santana is 87 years old and married to Adam. They reside in this home which they have lived in since they were married. She stated "I am Native American Indian and I was born here at San Ildefonso. My ancestors all came from here". When asked how many years she attended school she stated A. "Eight years, at the Santa Fe Indian School and I studied basic classes." She described the manner of earning a living was "pottery making, and I still do the work. Do you like my work? This is Adam's work. I learned pottery making from early days and I did it with my mother-in law." I responded by telling her that it is very beautiful and I know about her work and also of Adam and Maria's pottery. She was pleased and we continued the interview. Adam participated in the meeting and answered for Santana. When asked how many children they have, he stated A. "We have eight and some adopted children. One son died in a car accident and he had problems. Another one also died." When asked how many grandchildren they had, A. "We have so many it hard to keep track. . Adam answered "so many I cannot count them ... l4-20." Viola substantiated this fact and did attempt to name them. At one point in the visit a grandson came into the house and we were introduced. Viola informed him of the reason for my visit. Adam also stated "I am Native American Indian from New Mexico and my mother and father are Maria and Julian. I went to the Santa Fe Indian School also."

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130 When Santana answered the OARS illness Questionnaire she indicated she had arthritis, high blood pressure, and diabetes Her responses to the Geriatric Depression Scale (Short Form) indicated that "sometimes" she feels happy. She also stated that "sometimes" she is in good spirits When asked if she was full of energy, she responded A. "not really". Adam indicated that he has visual problems and cataracts, diabetes, and prostate problems when asked the questions from the OARS illness Questionnaire. He exhibited a great deal of hearing loss and questions had to be repeated many times He has a shuffling gate and needed assistance getting out of chairs. He scored 3 on the Geriatric Depression Scale (Short Form) and responded "sometimes" when asked if he is happy and if he feels full of energy. I was invited to participate in a pottery firing which was being done by a daughter of Santana and Adam. Several visiting Chinese students and their professor were also going to be present. Adam and his grandson were also participating. The family pots were going to be fired and they commenced early in the day We were welcomed by the potters and asked not to take any moving pictures or videos We were given permission to take photographs of the process and the participants. Adam was pleased by the presence of the visitors and warmly welcomed me and remembered my visit and the interview. I asked where Viola was and he stated that she was visiting her children that day

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131 Adam visited with the professors and Chinese students His grandson was assisting Adam's daughter in preparation for the pottery firing He described the process for everybody He enjoyed telling how the old ones learned how to use dung for fuel and to enclose the fire with steel in order to tum th e clay red and then black. This process produces the colorations of the pottery which is known as San lldefonso His grandson talked about the priests who v isit the Pueblo to say the Mass. He said that "the new priests we do not know and I will not ask them to do anything for me." Adam responded by saying "the old one (priest) used to tell us what to do he had rules, but when you needed them they were not there I don't go to church The preparation and firings took place durin g a three hour period All the guests were helping gather the dung for the fire. It was very hot near the shed where the steel is stored between firings After the firing the group was invited to the home of Adam's niece who is a friend of the local anthropologist who brought the Professor and Chinese stud e nts Adam stated "I am tired and will go home He was taken home in his grandson's truck. The mother of Adam s niece lived in the home She is in her nineties She states, I do pottery and would you like to see it?". Her daughter brought out the many pieces that the family created and the Chinese students eagerly purchased the pieces The pieces were quite different than the Adam and Santana pottery. The pieces are primarily animal r eplicas.

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132 Adam's niece spoke to the anthropologist about their work related to woman's issues The niece's husband returned to the home and greeted all of the guests He was a friendly man who began telling the students and professors about the history of the San Ildefonso Pueblo and pointed to the Black Mesa which is in clear view in his front yard He proceeded to tell the group "The Tewa went to Black Mesa when they broke from the Spanish. The Black Mesa is called 'Tunyo' and you can see it is here at the north end of the village The Rio Grande River is over there and we have to cross the bridge to Santa Clara you know where the clinic is .. .it's called Powgoge .". After our visit we were invited to a local barbeque and the group was going on to the home of an anthropologist in Espanola. The group was also invited to an Pueblo Indian celebration in Bandelier National Monument. Ethnographic Description and Themes of English Persons in Lincolnshire England The English respondents selected for Bloch s Ethnic / Cultural Assessment are representative of persons from a retirement living scheme and two activity centers All of the respondents report having chronic illnesses. One respondent indicates that her hip fracture limits activities and she is depressed The other two respondents accept their illnesses and report they have adjusted. The depressed respondent does not see her children, grandchildren and friends very often She also reports severe limitations of activities and feelings of depression She feels helpless and hopeless

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133 The respondent who is visually handicapped feels happy because she sees her family and friends regularly Another feels he is happy because he continues to be involved in activities, although he reports having many illnesses Each of the respondents lives independently in retirement housing with other aging persons Ethnographic Description of English persons in Lincolnshire, England Interview with Respondent #4 Kitty stated "I was born in London and I'm ninety-one years old My parents came to Manchester from Russia I went to school from age five to fourteen I'm a milliner. My parents made hats too I loved the business and wish I could do it now." "I've been widowed for twenty years and the wo r st thing is my broken bones I live in Keyworth up here I moved here with my husband and I miss London People treat me well here and they are friendly I don't like to be social all of the time "I am Jewish and the people are nice to me I belonged to the synagogue in London but not up here I see my friends once a week, but I come here because of my hip replacement." When Kitty was asked about her children, she stated A. "I have four 3 boys and 1 girl. My second son is not married and I live with him He is good to me. When asked how many grandchildren she has, she responded

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134 A. "I have 5 grandchildren I see some of my children every day, but not the ones down in London I see my grandchildren every week When Kitty responded to the OARS Questionnaire about lllnesses, she stated I have broken bones and I fall and that is why I had my hip replaced She also stated she had a great deal of arthritis She has chronic bowel problems and ulcers which have been treated. "I have a good heart." When responding to the Geriatric Depression Scale (Short Form) Kitt y was found to be moderately clinically depressed with a score of 6 When asked, "Are you afraid that something bad is going to happen to you?" She responded A. "What will be will be." When she was asked, "Do you feel that your situation is hopeless?" She responded with a "yes". Kitty also responded that her life is empty she has reduced her activities, and she gets bored. "I wish I could make hats like I used to This response summarizes her affective feelings Interview With Respondent #5 Ms Hitchcock is and 82 year old woman who lives in Witham in a retirement community which is provided by the British Government. The retirement flats are either townhouses or apartments Retired individuals qualify for these flats and they frequently wait for 2-5 years for one to become available.

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135 They reside in a supervised living setting, their meals are provided and socialization occurs If they become ill, they can be transferred to a hospital or a long-term care facility until they are able to return Ms. Hitchcock lives in this type of living facility. I met her on a visit to this retirement center to interview the elderly in Lincolnshire. Hillary is her daughter-in-law and we were surprised to meet again Hillary was the director of Age Concern m Grantham when I established my international experiences for students in 1982 Ms. Hitchcock is an open person who was very willing to talk about herself and her life She was born in Kent. She stated "you know it is South of London, and very pretty She indicated that she had a happy childhood, "even though the war came and it was hard." She attended school from age five to age sixteen. She became a dressmaker and moved to London "This was very exciting and then I was asked to take a job for Marks and Spencer in Kent The job was excellent and the pension is also very good She married and had three children. She is now widowed and states "I miss my husband its been a long time She has five grandchildren. She sees all of her children and grandchildren weekly. She asks for affirmation by stating "Isn't it wonderful!" She sees persons who reside in the retirement center and gather to eat daily She states "I do not see old friends only occasionally She is a member of the Church of England, but does not attend services regularly

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136 When asked about illnesses using the OARS Questionnaire she reported having macular degeneration of her eyes. Ms Hitchcock i s not depressed with a score of 4 on the Geriatric Depression Scale (Short Form) She stated "I listen to the record books because I always liked to read A question asked was "Are you in good spirits most of the time?' A. Her answer was "Sometimes When asked "do you think it is wonderful to be alive now?" A. Her response was also "sometimes" even though she answered yes" to the question from the Geriatric Depression Scale (Short F orm) When Ms Hitchcock was asked "Do y ou feel full of energy?" A. The response was yes but the weather is often drissly Ms Hitchcock eats with other members of the ret i rement center twice daily and has tea in the morning and afternoon During this time she socializes with old and new acquaintances She also indicated that the food is good and is "very much like we Brits eat you know lamb and good garden veggies." Ms Hitchcock does not attend church regularly but ind i cates she is a member of the Church of England and does go for spe c ial services and holidays Members of her church come from the area around Grantham and they do not attend regularly She also indicated that she is happy in Lincolnshire and does not have a desire to travel t o London and other places any longer He r basic satisfaction is evidenced by her ability to accept her life as it is.

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137 Interview with Respondent #6 Les is a 7 5 year old man who is divorced He states "I am retired and I am a civil engineer. I spent my early years in the R.A.F (Royal Air Force) on the gun turrets He was born in Manfold East Anglia, which is adjacent to Lincolnshire "I was a farmer until the war, then I went into the R.A.F I was with the 8th American Tactical Air Force in Sicily during the war. I still keep up with the American chaps They write and so do I. I went to America once and visited. He is dead now Les went to school from grades 5-14 He studied some engineering He states "I live in four rooms now that I am retired I have a garden Would you like to come by and see it?" He has been divorced for many years and he does not have any children When asked, what is your religion, he responded, A "Anglican, like all of us here "I have morning tea with the ladies I play dominoes and cards here with the men Would you like to meet me here later at the pub before I go for lunch Les sees his friends daily and visits them and community friends he meets at the pub I responded, "I have to go to another retirement center but when I return for the bus, I will call on you again

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138 When asked about his illnesses using the O.A.R.S Questionnaire, he responded, A. "I have heart trouble, and I had a little stroke 3 years ago It didn't do too much I had phlebitis and use blood thinners I take them three times a day When Les was asked questions from the Geriatric Depression Scale (Short Form) his responses indicated that he is adjusted to the aging process and he scored 0 Depression was absent and his responses were firm and no hesitancy was noted When I returned in the afternoon he was waiting with a gift The gift was a Royal wedding plate with a picture of Diana and Charles I was urged by the warden of the retirement scheme to accept this because Les would be "terribly hurt if you refused Les stated "I have nobody else to leave these things to but my friends, and I would like my American friend to have this." Ethnographic Description and Themes ofEuro-Americans in Polk County, Florida Chronic illness is the major variable which is reported by this population of aging persons in this community. The most severely depressed individual in the study resides here and he feels he is both helpless and a burden to his family. He also feels that he is unable to do activities for which he is responsible The costs of medical care are also of great concern to him and adds to his feelings that he is a problem for his family He also does not see his children and grandchildren very often He also reports feelings of hopelessness

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139 The second depressed individual in this group is also a man and he feels useless and it not satisfied with his life He feels helpless and that he is a burden since he became ill and cannot carry on routine activities The respondent who is not depressed is able to function well has not chronic illness She is also able to live a lifeway which is a continuation of when she was engaged in teaching Depression in this population is also affected by the presence of chronic illness and the lack of interaction with family and friends Ethnographic Description ofEuro-Americans in Polk Co u nty Florida Interview with Respondent #7 Frank is a 67 year old Caucasian male who lives in Lakeland Florida He lives with his 65 year old wife and they have six children He was born in Westbury, New York and came to Florida as a young man His mother was born in New York of German ancestry and his father was born in Italy His father came to Louisiana when he immigrated and then mo v ed to Long Island New York. Frank came to Florida forty years ago He met his wife in Polk County and they have been married for thirty-five years They have 6 children and 13 grandchildren He and his wife see their children once a month and at holidays He sees his son Robert "once in a while" He sees the i r g r andchildren approximately once a month

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140 Frank states, "I cannot read and that bothers me I went to the fifth grade in school in Westbury, New York. I worked for the Republic Air for nine years in maintenance I had a heart attack in 197 4 and I retired." When Frank was asked questions from the Geriatric Depression Scale (Short Form) he scored 11 which indicates that he is severely depressed When he was asked is he satisfied with his life, he said "no" When he responded to the question "do you feel that your life is empty?" he said A "I can't do what I'm supposed to do The question "are you afraid that something bad is going to happen to you?", was answered in the following : A "They can't fix my legs and my legs won t let me do things." Frank was asked "do you feel full of energy?" and he responded A "I can't do nothing anymore, my mind says yes and my body no." When he responded to the question, "do you think that most people are better off than you are?" he responded by saying, A "Yes and no people are worse off than 1". When Frank was asked the O A.R.S Illness Questionnaire he responded by saying he had a great deal of "arthritis, emphysema, high blood pressure, ulcers, hernia, liver disease and heart and circulation problems in his legs "I know I'm going to die from these legs."

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141 Frank and his wife were also upset because the medications he takes cost $800 00 per month and he cannot afford them from his Social Security Disability money His wife works as a cafeteria aid in the Polk County School system and she earns $13 ,000 per year which helps pay the medical expenses not covered by Medicare Disability Insurance. He is in need of her assistance and care because of his disabilities She is planning to retire and care for him at home Frank is depressed because of his multiple illnesses and hopelessness related to his chronic circulatory insufficiency and heart disease He does not see his children and grandchildren often and sees his friends only "for special occasions" He is totally dependent upon his wife for social interaction, care and well-being Interview with Respondent #8 Jean is a 69 year old Caucasian woman who is widowed for several years. She was born in Mulberry, Florida which is in Polk County. Her ancestors were from France and England and migrated to Alabama North Carolina and Plant City, Florida. She is Protestant and identifies her heritage as "European" She has two children and three grandchildren. She sees them weekly. She resides alone in Mulberry When asked about her last grade completed in school she replied,

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142 A. "I have a Masters' degree in Secondary Education and Guidance I graduated from Florid a Southern College a long time ago and then earned my Masters from the University of South Florida." She retired from teaching and being a guidance counselor in 1989 Since that time she does part time work associated with guidance and counseling as well as volunteer work with the elderly. She participates at the Senior Center Congregate Program Jean scored 0 on her Geriatric Depression Scale (Short Form) and was interested in the questions but did not respond by add i ng comments to them She reports only one illness which is high blood pressure whi c h is controlled by diet and medication She also responded by saying "I don't have any problems with financial worries because I make a good income and medical expenses are none She is a well adjusted individual who is aging with the ability to socialize and continue her life-long interests in teaching Interview with Respondent #9 John is a 81 year old man who is married. H e has lived in Polk County, Florida for 27 years He was born in Henderson, North Carolina "I am a geneolologist and I have written 300 pages about my family I am a Danalley We came from Wales 15 generations ago .. .it was the 1600's My mother's family came on the Mayflower and settled in East Virginia. They are McCully's The y settled James River Charles City, and Harrison We re Protestants." When he was asked what grade he completed in s c hool he r e sponded :

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143 A. I went to 14 years of school. I went to school in '32 to Duke University in Pre-Med It was the depression and I had to get a job as a bouncer in a night club Then I had to drop out because of the money I would have been a good doctor." He worked for Agrico in phosphate for 22 years They resided in Savannah, Georgia and Alexandria Virginia He also lived in Florida for several years and worked for Agrico He retired in 1975 when he was working on a sodium fluoride project. He and his wife live with their daughter and they have two grandchildren One daughter died in 1984 when she was 36 years old "This was hard on us, my wife especially When he answered the O.A.R.S Questionnaire he gave a detailed description of a kidney transplant which was done a few years ago. "It is very expensive to pay for the medicine which I have to take I have high blood pressure which is why I had the stroke I have some arthritis and my eyes give me trouble too I have cataracts." John responded to the questions on the Geriatric Depression Scale (Short Form) with expanded answers He said, "I am not basically satisfied with my life since my stroke When asked, have you dropped many of your activities and interests?" He answered A. "It changes everything." He answered "I am tired" both to "Do you often get bored?" and "Do you feel full of energy ?

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144 John scored 11 on the G.D.S which indicates that he is severely depressed He also indicated that he often thinks about his "Grandmother's house and death is nearby." John has 5 chronic illnesses and secondary affects from those illnesses He sees little hope for his life even though he has a supportive wife and sees his children daily. He also participates in the Congregate Dining Program. The Summary of Individual's Responses to Bloch's Ethnic/Cultural Assessment and Participant Observation During participant observation and discussions with the respondents of Bloch s Ethnic / Cultural Assessment (1983) biographical information and the AIDE (Lamm 1989) provides the following information. More Native Americans report that they reside alone than the Euro-Americans and British. Fifteen of the twenty-three respondents live with a spouse, children, and/or grandchildren The eight individuals who reside alone live in the Pueblo near their families Seventeen Euro-Americans of the twenty-five respondents reside with family members while only eight live alone Twelve individuals are married and live with their spouse while the remaining five live with their children and grandchildren Eighteen of the 29 British respondents reside with family members. Four live in congregate living settings and eight individuals live alone. Fifteen individuals are married and reside with their spouses

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145 In the total population (n-77) only five persons are divorced, one is Native American, two are Euro-American, and two are British One individual from each group a total ofthree never married Ofthe depressed population (n=21) ten remain married and living with their spouses, seven are widowed and three are divorced The workstatus of the individuals from the three groups varies a great deal The British are all retired None remains active in their work or professions Several report keeping busy with gardening Several individuals invited me to see their gardens They did not participate in volunteer settings or secular or religious groups Many were members of clubs such as the Rotary One respondent talked about his visits with Americans at Rotarian meetings in England The Euro-Americans have the greatest number of persons who are actively employed. Four persons work and one individual is involved in volunteer service where she is in charge of a craft program at a multi-purpose senior center The individuals who work are ages 59-65. The British have individuals in the young-old age group, but they have all retired at age 55 which is normal in Great Britain Four Native Americans also remain working and receive wages for their work. The director of the Congregate Dining Program is 56 years old and intends to remain working as long as her predecessor who retired at age 73. The three other working individuals are ages 56-65 The major difference in the Native American population is their involvement in pottery making. They continue to make pottery in the family unit and the family sells the pottery in shops and at festivals. Twelve individuals remain artists and make pottery

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146 This type of avocation was not reported in the Euro-American or British populations The number of children varied greatly between the populations. The Native American population reported between one and nine children As a result they have three to fifty-four grandchildren Many individuals asked "do you want to know about my adopted children too?" In direct relationship to these children and grandchildren, their visits with one or more of them was daily This is relevant since the Native American population has the greatest number of respondents living alone One individual who never married adopted two children and sees them daily The Euro-Americans have an average of three children per respondent. They also have many grandchildren with a range between one and thirty-two. They report a wider variance in visits per week. The range includes, none three times per year, eight times per year once yearly and daily. The person who never married lives with her niece and sees her daily. The British report the least children with a range of none to five As a result they have the fewest grandchildren which is between none and eleven In direct relationship, the visits per week drops to two while one person visits family once per month. Nine persons see their children once a week. They had the greatest number of persons who never had children which was six Only one of the six was never married The majority of Native American respondents see friends daily Only six of the twenty-three report seeing friends only once per week Of these individuals all visited daily with their children and grandchildren

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147 Most of the Euro-Americans visit friends daily Five individuals report visiting friends only once per week and they have physical limitations One respondent is isolated from friends and family and scored highly depressed on the Geriatric Depression Scale (Short Form) and reports feeling sad ". The greatest number of respondents who report not visiting friends daily are British Thirteen individuals see their friends once or twice weekly They report that their friends often do not come to congregate senior programs with them In the depressed population of the Native Americans three of the five respondents report less daily visits from friends and family members All of the Depressed EuroAmericans respondents report no visits from friends on a daily or weekly basis Seven British respondents of the nine depressed population do not see friends weekly or monthly This population has the fewest social visits from children, grandchildren and/or friends. All of the respondents in the British population reported no medical expenses related to their illnesses and no resulting stress from these concerns. Only two NativeAmericans report expenses re l ated to illness. In the Euro-American population five individuals report high medi c al expenses related to their illnesses and increased stress related to this situation The religion of twenty Native American respondents is reported to be Roman Catholic Three individuals stated they are "Anasazi and culture rich Ten of the respondents attend church regularly I attended Mass with several of the respondents on Sunday

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148 Six of the women attend Mass whenever the priest visits the Pueblo Church of San lldefonso. One male respondent is a Lay Deacon and his family attends Mass with him Five elderly women stated they are Native American and Catholic indicating they can be both. One man reported being angry with the church and particularly the "old priest who tells them what to do None of the young people listen to him and they don't want to get married in the church This group and their individual ethnographic information indicates the cultural integration which has occurred since their contact with the Spanish and Euro-Americans The Euro-Americans who participated in the study reflect the pluralism of the culture of the United States. There are 15 Protestants from six religious affiliations Nine individuals are Roman Catholic and one is Jewish. Twelve of the 25 respondents stated they attended services regularly and they all viewed themselves as practicing their religion. In the British population 28 respondents reported belonging to the Church of England One individual is Jewish. All of the individuals interviewed indicated that they do not attend services on a regular basis Individuals reported being members of the church from birth and relating to the religious participation as something one does when baptized, married, die, and celebrate Christmas This group reflects the homogeneity of the British population I attended services at St. Wolfram's Parish and there were many elderly persons in attendance In the total population of the three culture groups 43 of the 77 individuals are male. Since the sites for selection of all respondents were pre-determined this may account for the presence of more females

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149 This disparity reflects the demographics in post-industrial societies which indicate that women live six years longer than men Participants in the congregate sites have been referred and they also attend by choice Females are often more likely to participate in socialization programs (Atchley 1995). In all three culture groups the 55 to 59 age groups had the fewest respondents which is less than three In the age group between 60-69, the Euro-Americans had the greatest number which is 7 of the 25 respondents The Euro-Americans have the greatest number of old persons over ninety which is 5 of the 25 respondents The Native Americans have 3 and the British have 2 respondents over age ninety In the depressed population of (n=21 ), nine individuals are in the 70-79 age group Since this group represents 43 percent of the total depressed population and only constitutes 28 percent of the respondents there is an indication that this age group is more at risk to develop depression This group also has an increase in the number of chronic illnesses which is 4 per individual. This is much greater than the group average which is 2 7 per individual The languages spoken are the greatest in the Native American population because of their culture which supports the teaching of Tewa English was the language this population learned at the Indian Schools and Spanish is a language that is spoken in this area of the South Western United States Many of the participants indicated they learned Spanish when they were young and know how to speak the language The Native Americans also have the highest level of education because twenty of the respondents graduated from the Indian High School and two had gone on to earn nursing degrees.

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150 Each of the respondents selected for the Block Ethnic / Cultural (1983) interview indicated they were interested in further discussing their life histories. Each respondent added insight into why they responded to identified questions Common themes, as previously noted in the depressed population centered around the presence of multiple chronic illnesses the lack of socialization and the feeling that they can no longer participate in work or activities which they once did Respondents who are not depressed indicate that they feel they are participating in socialization with adjustment and they feel positive about their lives This ethnographic information gives further insight into the results of the quantitative information which is reported in Chapter 5.

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151 CHAPTERS RESULTS OF STATISTICAL ANALYSIS OF FINDINGS Introduction The findings of this study are presented in this chapter in the following order: first, the summary and analysis of descriptive characteristics of the three selected populations in the study are presented in Section I. Then, in Section II, the statistical analysis of the relationships among the selected variables and their associations with the dependent variable of depression are presented Section ISummary Characteristics of Three Populations Selected for Study Seventy-seven persons from three distinct populations responded to the Age, Illness, Depression, Ethnicity questionnaire (AIDE Lamrn), The Geriatric Depression Rating Scale (Sheikh and Yesavage 1986) and The Chronic Illness Inventory (The OARS Methodology 1975) Twenty-three respondents are from the Tewa Pueblo population of San Ildefonso, Santa Clara, San Juan, Nambe Tesuque, and Pojoaque pueblos Twenty five respondents who participated are Euro-Americans from Polk County, Florida

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152 Twenty-nine British respondents represent another European population, outside of the United States Five persons from each of these populations provided data for the Block Ethnic/Cultural assessment (Figure 1 )

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Euro-Am. 25 33% Figure 1 Population Totals (n= 7 7) British 29 36% 0 . . . . . . . 0 0 0 0 0 0 Native Am. 23 31% 1 53

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154 Thus of the seventy-seven respondents, thirty-six percent are British from Lincolnshire and Nottinghamshire England, Thirty-three percent are Euro-Americans from Polk County Florida, and thirty-one percent are Native American from the Indian Pueblos of New Mexico (Figure 1) The mean age of the respondents is similar with the Native Americans being slightly older at 77, the British are 75, and the Euro-Americans are the youngest at 73 years of age (Figure 2 and Table 1 ) When the total number of chronic illnesses is analyzed, the British account for 34 .31 percent of all illnesses, the Euro-Americans 35 30 percent and the Native Americans 30.41 percent (Figure 3). The Tewa pueblo population reports less illness than the EuroAmericans and British Within each group the mean number of illnesses is 2 5 for Native Americans, 2 9 for Euro-Americans and 2 8 for the British (Figure 3 and Table 1) The total number of depressed individuals as indicated by responses to the Geriatric Depression Rating Scale (Short Form) is twenty-one from the total population of seventy-seven There are five depressed Native Americans, seven depressed Euro Americans, and nine depressed British respondents The British are the most depressed representing forty-three percent of the depressed cases ( n=21) while representing thirty-six percent of the total population (n=77, Figure 4) The Native Americans are the least depressed and represent twenty-four percent while the Euro-Americans represent thirtythree percent of the total of twenty-one depressed persons (Figure 4) The British have the highest rate of depression with a ratio of one depressed person per 3 2 individuals, the Euro-Americans rate is one per 3.4 while the Native Americans are lowest with one per 4 3 (Table 1).

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essed Population n=21 I Population n=77 American n=23 '-Am ericans n=25 sh n = 29 Table 1 Population Totals, Mean Age, Mean Number of Illnesses Per Person, and Number of Depressed Persons in Population Mean Age Number of Illne sses No Dep Percent of Dep Pers o ns Illness Ratio Per Of Population Persons Within Group Individual in Oep Population 4.0 n=21 74 8 2 7 n=21 2645 I Jb 76 8 2.5 n=05 22.22 143 73 I 29 n =07 25 00 I J 4 75 03 28 n=-09 3214 1 .32

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80 Figure 2 Mean Age of Tolal Populalio n (n =77 ) --------. --------. ---------... . 60 ... 40 20 0 Native Am. British Euro-Am I.J 0

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u ro ; \ tn : 3 s. :j 157 Figure 3 Percentage of lllnesses in Each Population B r ilis h 3 < 1 3% N u L i v e i-\ 111 e r 30A%

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Native A m 23.8% Figure 4 Percentage of Depressed Population (n=21) Euro-Am. 33. 3 % British 42.9% 158

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159 The British also have the highest r ate of depression within their population, with a rate of thirty-two percent of twenty-nine respondents (Figure 5). The Native Americans are the least depressed with an ingroup rate of twenty-two percent of twenty-three persons (Figure 6) The Euro-Americans reflect a twenty-five percent depression rate i n the population oftwenty-five (Figure 7 and Table 1). Comparing the number of cases of illness and depression, one finds the number of illnesses in the depressed population of (n=21) in c reases to a rate of 4 0 per individual from a rate of2. 7 per respondent in the total population (n=77) (Table 1) The following discussions will describe the differences among these three populations in terms of other variables sele c ted for anal ysis: (1) How many person's live w ith the respondents ; (2) Their work status ; (3) Medical expenses ; ( 4) Number of children ; (5) Number of visits with children per week ; (6) Number of grandchildren; (7) Number of visits with grandchildren per week ; (8) Visits with friends per week ; (9) Number of years of education ; (10) Languages spo ken; (11) Religion ; (12 ) Income; (13) Gender ; (14) Marital status; and (15) Identified culture In the Euro-American population the number of individuals the respondent lives with turns out to be a significant variable in relationship to depression Euro-Americans tend to live with the most family members ave r aging 2.6 persons per household More N ative Americans and British live alone The Native Americans l i v e near more children because of their reservation habitat, but apparentl y not in the same households (Figure 8 and Table 2) This information reflects the importance of the social support network.

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160 Figure 5 Depressed British Population (n=29) ( 3 2 1 4 /o) (67.86/o)

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161 Figure 6 Depressed Native American Population (n=23) Native Am. (22 22/o) (77 .78/o)

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162 Figure 7 Depressed Euro-American Population (n=25) Euro-Am.

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1 63 Figure 8 No. of Individuals Respondent Resides with Workstatus Medical Costs J .() -------------------.. ----. -. ::> r. . ) -:2. () -I !) I 0 -o o I Workstnl.. How many persons reside with respondent Work Status Medical Costs : 1. None; 2. Moderate ; 3. Great. 1 e d C o

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164 Tab l e 2 S u pport in Househo l d, Wo r kstatus, Medical Cost How Many Persons Workstatus Relative Medical Cost Reside with Respondents Native American n = 23 2 .3 1.4 0 .75 Euro-Americans n = 25 2.6 1.90 1.8 British n =29 1.9 2 0 .00 *(1) Actively working; (2) Retired; (3) Avocation *Relative Medical Costs: 1. None to Low; 2. Moderate; 3. High In the total population of seventy-seven, fifty-five percent are married persons It is important to note that only five p ersons are divorced which represents only seven percent of the total population Three persons were never married and thirty-five percent of the individuals are widowed The Euro-Americans have a significantly higher number of divorced individuals Fo r all populations there are higher numbers of married persons than single, divorced and widowed (Figure 9 and Table 3). Table 3 Marital Status Married Divorced Single Widowed Total Popu l ation n=77 55 7 3 35 Native American n = 23 44 II 43 Euro-Americans n =25 50 12 48 British n =29 5 1 1.5 .05 47 *Percentages The Native American population ha s a significantly gre ater number of persons involved in an avocation These person s are artists who are involved in creating artwork and pottery. A ging does not apparently inhibit these activities

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1 65 Figure 9 Marital Status of Each 20 I 0 ;...-I i :) I I 0 -. Married Widowed Divorced Sing l e Nut. ive .A.m E t1 ro-Am. CJ Britis h

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166 These persons become more involved in creating and participating in the art of pottery and reservation life after their retirement from jobs in nearby cities Individuals who are not artisans are also active in family businesses which promote Native American products and tourism (Figure 8) All of twenty-nine British respondents have retired. Many individuals reported several careers during their lives Some had served in the military or government service, finally retiring to do odd jobs in the community. Many had been farmers who raised animals and grew crops but they left agricultural work during and after the war when it was more advantageous to work in factories In retirement this population has retirement housing available and activities as well as medical services (Figure 8) In the Euro-American population four of the twenty-five persons remain in the work force and their ages range from fifty-seven to sixty-seven Many of the retired individuals are active in social and volunteer activities The men report dissatisfaction with not working (Figure 8). The British report no medical expenses related to their illnesses, while the Native Americans and Euro-Americans report low expenses (Figure 8). This is quite relevant since depression and dysphoria are often said to be to financial costs of illness in the general population in the United States (1994 Atchley ; 1975 Butler; 1994 Kart) There is a great difference among populations in number of children they have had. The Native Americans have had twice as many children as the British. The number of visits from their children has a direct relationship to the numbers of children.

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167 The weekly visits of the Native Americans are 5, the Euro-Americans have 3, and the British have 1.5. This correlates with the average number of children which is 4 7 for the Native Americans 3 5 in the Euro-American population, and 2 3 for the British respondents (Figure 10 and Table 4). Table 4 Social Support Network No. ofChil dren Vis its No. Grandchildren Visits Friends Visi ts Native American 4.7 5 12 4 .8 4.5 Euro-Ameri cans 3.5 3 7 2 .8 4.5 British 2 3 1.5 4 1.8 4.5 The number of grandchildren is greatest in the Native American population which has three times the number the British have The Native Americans have an average of 12 grandchildren, the Euro-Americans have 7, and the British have 4. The weekly visits are not correlated with these numbers although the Native Americans see their grandchildren more often at a rate offive days per week (Figure 10 and Table 4) Continuing evaluation of the socialization patterns of each population indicates that all of the populations value interaction with friends This is reinforced by the participation at the multi-purpose centers The visits with friends average 4 5 per week in all populations (Figure 10 and Table 4). Education is very similar in all three groups The mean years of education for the entire population of this study is 1 0 2 years, which reflects well the demographics reported for persons over 65 years of age in the United States (1994 Atchley). The Native Americans were educated at the Santa Fe Indian School which most attended for 12 years, and many studied nursin g afterward

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Figure 10 Number of Family Members, Friends and Visits.L4 ---------1 2 -lO G -, 2 a N o Child Child V i sils N o G r d Number of Children Number of Children' s Visits Number of Grandchildren Number of Visits from Grandchildren Number of Friends Visits .. Nnl.i v e A m Euro-AnL Visil G r fi'r V i sil c=J Bril i s ll 1 68

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169 The British population almost uniformly completed 9 years of formal education. The Euro-Americans were more varied in their education with a range from 5 years to one Doctorate The Native Americans spoke the greatest number oflanguages Tewa, Spanish and English, reflecting their cultural heritage Almost all of the Euro-Americans and British spoke only English (Figure 11 and Table 5) Table 5 Religion, Years of Education, Language Spoken Pro t Ca th. Jewish Anasazi Ye ars Ed Langua ge Total Populatio n 44 2 8 2 3 1 0 .2 1.69 Euro-Americans 1 5 9 0 1 0. 5 1..3 Na ti v e American 0 20 0 3 1 0 3 2 .. 9 B rit is h 28 0 0 9 .8 1.07 The religions of the Native American pueblo populations are reported to be Roman Catholic Three irldividuals stated they are Anasazi and Culture Rich" Eight women reported they are Roman Catholic although they are "Pueblo" Nine persons in the Euro-American population of twenty-five persons report they are Roman Catholic and one male is Jewish The remainirlg fifteen respondents are Protestant. In the British population twenty-eight persons report their religion as "the Church of England" which reflects their culture One female is Jewish who was born in Russia and immigrated to Great Britain as a child This population is the most depressed although there is no statistical si g nificance irl the relationship between reli gi on and depression (Figure 12 and Table 5)

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170 Figure 11 Illnesses Yean of Education Languages Illnesses Yrs. Educ. L a nguages .. Nat. i v e Am. Euro-Am. c=J Britis h

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.-, .) :-] :JO -25-20 ; _ I I I -\ l :) I I I i l 0 :--1 I I I L :) 0 Catholic Figure 12 Religions of Each Populati on ,--. I i I I Protestant Jewish .. Nalive Am. E u r o ...\ m Anazazi c=J British

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172 The gender differences among the populations in this study are noteworthy Females number forty-four of the total of seventy-seven respondents and males thirtythree (Figure 13 and Table 6) This is the expected difference in populations of persons over sixty-five years of age There are nine females and twel v e males in the depressed population of twenty-one Fifty-seven percent of the men are depressed in contrast to forty-three percent of the females (n =21 ) although women are fifty-seven percent of the total population (n=77) (Figure 14 and Table 6). Table 6 Gender and Depression Male Female %Mal e %Female Total P o p. n =77 33 44 42.9 57. 1 Degressed Pop n = 21 12 9 57. 0 43.0 Section II-Statistical Analysis ofMultiple Variables and Depression Instruments Using the Statistical Package for the Social Sciences (1994 SPSS 5.0 PC) cross tabulation Pearson's Chi-Square Probability calculations various correlations, factor analysis and regression analysis were used to further analyze these data from the three populations Anthropac (Borgatti 1 99 2a) was also used to anal yz e the scalability of the items on the Geriatric Depression Rating Scale

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Figure 13 li3 Genders of Each Population Mal e s F e m ales .. Native Am Euro-Am CJ British

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Men 4 2 9% Women 57.1 % Total (n==77) Figure 14 Gender Differences M e n 57. 1 % Women 42. 9 % 2 1)

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175 The Pearson Product Moment Correlation Coefficient (R) and the Spearman Correlation Statistical Method were used to better understand the relationship between depression and the selected variables ( 1972 Labovitz). Measurements of the degree of association, either positive or negative, between depression and related factors were calculated Pearson's Chi-Square values were calculated for each of the paired compansons. For each variable measured, the degree and significance level of its association with depression were calculated This allowed an ordering of the importance of the measured factors in terms of relation to depression The Geriatric Depression Rating Scale (G.D .S. Short Form, Appendix ill) includes fifteen questions which were ordered so as to maximize the acceptance of the questionnaire and differentiate the presence and severity of depression (Sheikh and Yesavage 1986a : 37). As the G D.S (Short Form) was standardized when the individual responds to each of the 15 items, ten are indicators of the presence of depression when answered positively while for the rest (no's. 1, 5, 7 11, 13) the negative response is indicative of depression As the G D.S (Short Form) has been traditionally used, a score of one to five points suggests non-clinical depression six to ten mild depression and eleven to fifteen severe depression (Sheikh and Yesavage 1986a) The G D S was designed specifically for the elderly and its items were developed after careful consideration of unique characteristics of depression in the elderly (Sheikh Jarvick 1983).

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176 Hoping to achieve a finer, more graduated measure of depression than just three categories, non-clinical, mild, and severe Guttman Scale Analysis was applied to the Geriatric Depression Rating Scale (Short Form) The Guttman Technique attempts to determine the unidimensionality of a scale (Miller 1991:179) The items ofthe G D.S are ordered and the respondents are also ordered appropriately in terms of their responses Anthropac (Borgatti 1992a) was used to analyze the data in this way in hopes of finding a more sensitive, more reliable measure (Bernard 1994 : 296-297). The results of using scalagram analysis instead of traditional scoring of the G D S will be revealed in the sections that follow and can be seen in summary form in Table 10 The OARS Multidimensional Functional Assessment Questionnaire (1975 Appendix II) consists of several subsections The Chronic Illness subsection was the instrument used to measure the presence of chronic illnesses in the population (n=77) which was analyzed using the Statistical Package for the Social Sciences (1994 5 0 PC) The Age Illness, Depression and Ethnicity questionnaire (Appendix I) was analyzed and each variable identified and given a numerical code The information was measured ranked and further analyzed using the Statistical Package for the Social Sciences (1994 5 0 PC) Age and Depression In the present study, there is no significant association between age and depression probably because the entire population is old

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177 All seventy-seven persons range between fifty five and one-hundred and five, with a mean age of 74.8 There are more individuals in the 70-79 and 80-89 age categories than in other categories (Table 7) Table 7 Age Groups of Populations 55-59 60-69 7 0-79 80-89 90-105 Mean Age Total Popul a ti on n=7 7 10 14 23 20 9 74.8 Depr essed Population n = 21 2 5 9 2 3 75.0 N ati ve American n = 23 3 3 5 9 2 76.8 Euro-Ame ric ans n=25 3 8 5 4 5 73.1 British n-29 4 3 13 7 2 75.03 Within the depressed population of (n=21), 9 persons are between the ages of 70 and 79 There are only 2 persons between the ages of 80 to 89 3 persons between 90 to 105 5 persons between ages 60 to 69 and 2 are between ages 55 to 59 The high number of depressed persons in the age group of 70 to 79 is greater than their representative numbers in the total population of (n=77) They are 43 percent of the depressed population (n=23) while they represent only 25 percent of the total population (n=77) The individuals in this age group in the depressed population (n=21) have a mean of 3 .81 illnesses which is significantly higher than the other age groups (Table 1) There is a low correlation between depression and age of r=0 02 in the total population (n=77) When the ethnic populations are analyzed separately the Pearson Product Moment Correlation (R) increases to r=0 32 for the Native Americans remains a low r=O.l4 for the Euro-American population, and falls to a negative association of r=0.19 for the British

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178 The correlation ratio or Eta was used to measure the non-lineal relationship in the total population (n=77) and there is a significant Eta of r=0 60, (Table 8). In order to further test the relationships Regression Analysis was done and age had no significance at F=0 61. When the items on the Geriatric Depression Rating Scale (Short Form) are analyzed using the Guttman Technique, the association between age and the resulting depression scale remains insignificant at r=O.OOl (Table 8) Age and Depression ofG. D.S Pearson's R. Speannan Correlation Chi-Square Sig. Eta Guttman Table 8 Statistical Measurements of Age and Depression Total Population Native American Euro-Amer. 0 .02 0.32 0 14 0.10 0 .36 0.23 0 .74 0.61 0.30 0.60 0 .92 0 .89 0.0001 Chronic Illnesses and Depression British -0.19 The number of illnesses an individual has developed appears to be significantly correlated with the dependent variable of depression in the total population (n=77) as well as each population measured separately. The Pearson's R is r=0.42 and the Spearman Correlation r=0.40 (n=77) which indicates an association of the variables with an Eta of r=0.46 again suggestive of a non-lineal association. When the Native American population is analyzed separately the Pearson's (R) Correlation increases to a highly significant association of variables at r=0 62, a Spearman Correlation ofr=0. 66 and an Eta ofr=0.69.

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179 When the Euro-Americans and the British are analyzed separately the Pearson's (R) is r=0 38 (Table 9). The average number of illnesses for the depressed persons (n=21) increases to 4 0 for each individual from 2 7 in the total population (n=77) In the severely depressed population of individuals (n=5) who scored above 11 on the Geriatric Depression Rating Scale (Short Form) the number of illnesses increases significantly to 6 5 (Table 9) Chronic Illn esses Depression and N o Oflllness Sever e l y Depressed n=5 P earson's It Spearman Correlation Eta Chi-Square Pears o n' s ( R )-G u ttman Table 9 The Statistical Measurements of Number of Chronic Illnesses and Dep ression Total Popul ation Native American Euro-Amer British n = 7 7 n=23 n =25 n = 29 2 7 2 5 28 4 .0 4 0 4 0 4 0 6.5 0.42 0.62 0.38 0 38 0.40 0.66 0.46 0 69 0.17 0.18 0 3 5 In further analysis of depression with the items of the Geriatric Depression Rating Scale (Short Form), scaled using the Guttman technique, there is further support of the association with the presence of chronic illnesses at r=0 35 (Table 10). When chronic illness, as a variable is further tested for significance using multiple regression, there is evidence of significant contributions in the relationship with depression of F=O. 0003

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Table 10 Correlations of Selected Variables With Depression (Peanon's-R) Depression Measured by GDS with Depress ion by GDS Nuive American n -23 British n 29 Euro-Amcrican n iteml scaled by Gunman Technique Peanons R n n Peanons R Peanons R Peanona R n-n Age 001 0 02 0 32 0 .14 Chronic lllnc:sses 0 3S 0 42 0 62 0 38 0 38 Work statw 0 .12 0.44 0 20 Medical Costa 0 03 0.3S 0 03 0 .38 With whom the respondent resides (Social Support) 0 .20 0 28 0 17 O S I 0 .11 Nwnbc.of Children 0 .04 0 04 0 03 0 .41 0 03 Visiu peT week by childTen 0 .11 0 .12 0 30 0.38 Number of grandchildren 009 0 .41 V isiu peT week by grantlchi ldrcn 0 20 0.07 .003 Viaiu peT week by frienda Muit&l St.tw .000 0 .01 0 .37 Gender O J I Culture 0 23 0 .11 . Education 0 .11 Language spoken Religion 0 .02 0.03 .0000 0 .09 Income 0 .15 0 .10 .......

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181 The Social Support for Respondents and Depression One measure of social support i s the number of ind i viduals a person lives with This variable has a correlation with depression measured by the G D S in the total population (n=77) of r=0 .28 (Table 10) Since this correlation suggests a significant association with depression, factor analysis was done to determine the relationship among the several variables that are involved in social support These variables are the number of children, grandchildren and their visits the number of friends visits and workstatus (Table 11 ). Although the measure of association with depression is moderate social support has a moderate loading on factor II at r=0 .35 (Table 11) Regression analysis further reveals that this variable, numbers of persons with whom one resides contributes significantly to the relationship with depress ion (F=0 04) It seems the more persons an individual resides with, the more prevalent depression In the most depressed population, the British (n=29) there is a statistically high correlation with the number of persons an individual resides with, at r=0 .51 in contrast to the Euro-American correlation which is insignificant at r-0.11. The Native American population also has a statistically low correlation of association between these variables of r=0.17 (Table 10) When items of the G D S were tested for scalability using the Guttman Technique, the association between the Geriatric Depression Rating Scale (Guttman) and the variable of how many individuals reside with the respondent the correlation is r=0 20 (Table 10)

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182 Table 11 Factor All Variables Factor 1 Factor 2 Factor 3 Depression -0. 118 0 .407 0 572 Age -0.024 0 671 0.573 Numbe r of Illnesses -0 102 0 .476 -0.453 Workstatus 0 .204 0 441 0 16 3 Medical Cost 0.388 -0 346 -0 .206 Resides with O.D35 0 353 0 311 Number of Children 0 680 0.405 0 632 N umber of Visits Chil dren 0 532 0 .259 0 023 Number of Grandchildren 0.600 0 .418 0 .283 N umber of Visi ts of Grandchi ldr en 0 656 0 .106 -0 180 Friends Visits 0 250 -0 .5 40 0 .272 Marital Status 0.101 0.068 -0 001 Gender 0 349 -0 158 -0 .484 Race -0. 851 0.026 -0.426 Years ofEducation 0.128 0.418 0.209 Languages Spoken 0.786 -0 088 -0 081 Religion -0 .600 0.252 -0 .067 Inc o me -0 015 -0 .379 0.002 Using the more graduated measure of depression (The Guttman Technique), factor analysis of all variables in the total population (n=77) demonstrates an association between the variables of depression the number of illnesses, age and those related to social support which are moderately loaded on factor II with depression (Table 12). The number of friends visits is significantly loaded on factor II at 0 537 (Table 12) indicating a negative association. The variables of social support and social integration include; workstatus, how many persons reside with an individual, the number of children and grandchildren and their visits, and the number of friends and their visits

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Table 12 Factor Analysis Guttman Technique Depression-Guttman Technique Depression Age Number oflllnesses Workstatus Medical Cost Resides with N umber of Children Number of Visits Children Number of Grandchildren Number of Visits of Grandchildren Friends Visits Marital Status Gender Race Years of Education Languages Spoken Religion Income F actor 1 -0.226 -0 113 0 020 -0 116 0 .292 0 303 0 .052 0 650 0 516 0 601 0 .687 0 252 0.211 0 356 -0 845 -0 .004 0.799 -0 .636 0 .624 Years of Education and Depression Factor 2 0 71 2 0 722 0 484 0.607 0.331 0.095 0 .329 0 .297 0 255 0 .309 0 .094 -0 .537 0.135 -0 086 0 035 -0 301 -0 167 0 102 -0 1 2 3 Factor3 0.464 0 .538 -0 615 0 190 -0 241 0 568 0 .227 -0.191 -0.006 -0 .266 0 .054 0 169 -0 031 0 .052 -0 .078 0.472 0 .027 -0 .352 0.452 183 The years of education an individual acquired has a low negative correlation with the variable of depression in the total population (n=77) at r=-0.02. In a previous study the negative correlation was r=-. 78 indicating that the more education an individual has the less likelihood the presence of depression (Lamm 1989) In this current study, the Native American population have an insignificant negative correlation of r=-0 .11 between education and depression because most of the population have achieved the same level of education. The British population (n=29) also shows a low negative association of those variables at r= -0 .15 which also reflects uniform education in the population Even the Euro-Americans show a non-significant negative association between education and depression at r=-.06, and analysis using the Guttman Technique also shows a negative association at -0 .11 (Table 10)

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184 Workstatus and Depression W orkstatus is not significantly correlated with depression at r-0 12 in the total population (n=77). In the Native American population (n=23) the Pearson's (R) Correlation increases to r-0.44 and the Spearman Correlation to r-0.43. In the Euro American population (n=25) the Pearson (R) Correlation is also non-significant at r--. 02 reflecting a negative association The British (n = 29) shows a slightly higher correlation of r-0. 20 (Table 1 0) Of the five depressed Native Americans only one respondent is retired while four are active in an avocation All of the depressed British respondents are retired, while three of the seven depressed Euro-Americans report working There is demonstrated a association with the presence of depression in the Native American population (n=23) of r-0. 44, indicating more significance in the relationship when compared to the other ethnic groups When the Guttman Technique is used, factor analysis reveals that workstatus is moderately loaded on factor II with social support, depression, age chronic illness and medical expenses (Table 12)

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185 Medical Costs and Depression There is no statistically significant correlation between medical costs of the individual and the dependent variable depression in the total population (n=77) with a Pearson's (R) Correlation of r=-0 .17. When the Native American population is evaluated separately there is an association between costs of medical treatment and depression, with a Pearson's (R) r=0.35, indicating a moderate association (Table 10) When the Euro Americans are measured separately, the Pearson's (R) Correlation also indicates moderate association of the variables at r=0 38 In the British population, the Pearson's (R) Correlation is non-significant at r=0.03. The fact that health care is provided for the British population most probably explains the non-significance of this factor (Table 1 0). When the Guttman Technique is applied this variable is heavily loaded on Factor ill with depression, income, chronic illness and age (Table 12) The Number of Children, Grandchildren and Visits with Depression The association with depression of both ( 1) the number of children and grandchildren and (2) their visits per week is not statistically significant in the total population (n=77). The Native American population also has a non-significant association between depression and number of children at r=0 .03 but a moderate association with the number of visits per week at r=0.30. The number of children in the British population is more significantly associated with depression at r=0.41 and number of visits at r=0 38

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186 The number of children and their visits is apparently not significantly associated with depression in the Euro-American population respectively at r=0 .03 and r=-0.04 (Table 10). The correlation ratio (Eta) for the number of children in the total population (n=77) is r=0 34 which is suggestive of a curvilineal relationship which increases to r=0 62 in the Native American Population (Table 1 0) In factor analysis done on the correlation matrix of all three variables (n=77) the number of children and grandchildren and their visits are also moderately loaded on Factor II which supports the relationship of the variables of social support with age, depression and number of chronic illnesses (Table 12) Number of Visits from Friends and the Association with Depression The number of visits per week by friends has a negative correlation with depression of r=-0 22 in the total population (n=77) (Table 10) In the Euro-American population it is statistically significant at r=-0.47 (Table 10) and also significant in the Native American population at r=-0 38 (Table 10) There is also a negative correlation in the British population of r=-0 .05. In the total population (n = 77) the number of visits per week by friends is moderately loaded on factor II with other variables of social support at -0 54, indicating a negative relationship with depression (Table 11) Applying the Guttman technique, the negative correlation with depression increases to r=-0 24 in the total population (n = 77), revealing the more friends visit the less depressed the individuals are (Table 12)

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187 Gender and Depression A low correlation between gender and t he dependent variable of depression as measured by the G.D S. (r=-0.09) may be an artifact of differences in the percentage of males and females in the total population (n= 7 7) and the depressed population ( n = 21) (Table 10) There are twelve males and nine females in the depressed population which indicates that 57 percent of the depressed population is male and only 43 percent of the total population (n = 77) (Figure 14) This difference i s present in each population when measured separately. The Chi-Square was done because of the nominal category of gender was dichotomized against the ordinal mea s ure of depression using the G D S The Chi-Square is significant at 0 035 at the p= < 0 .05 (Table 13) Using regression analysis, the significant contribution of gender in the r e lationship with depression is supported at r=0 04 When an anal y sis ofvariance is done on depression by gender and the number of illnesses there is a significance at F=0 003 in the total population (n=77) G end er C ul ture R e ligion Table 13 Chi-square Results (n=77) Value df P=<.l 0 2 0.79 II 0 035 3 4 3 4 22 0 .0 45 29.92 2 2 0 .10 In the Nati ve American population (n=23) gender has a higher Pearson's (R) Correlation of r=0 .31 with an Eta of r=0.35 indicating a curvilineal relationship The negati ve assoc i ation with depression in the Euro-American population is v ery significant at -0. 58

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188 In the British population there is a non-significant negative association at r=-0 .10 (Table 10) Culture and Depression The association between culture", treated as three nominal categories and depression treated as an ordinal scale of three categories is not statistically significant at r=O.ll in the total population (n=77) There is a correlation of culture and depression scaled by the Guttman Technique at r=0 .23. When the 2x3 table depression dichotomized against the three cultures is submitted to Chi-Square Analysis the likelihood ratio value is 34 34 with a significance of p =< 0 .045. The differences among the cells are significant at p=< O .OS (Table 13) Different rates of depression are associated with cultural differences of aging individuals in this study Within the Native American population of Tewa Pueblo respondents (n = 23) the depression rate is 22 percent with a ratio of one depressed person per 4 3 respondents. The within group depression rate rises to 25 percent in the EuroAmerican population with a ratio of one depressed person per 3.4 respondents There is a significantly higher rate of depression within the British population of 32 percent with a ratio of3. 2 individuals for each depressed respondent (Table 14)

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Total Populatio n Native American E ur o-Americans British Table 14 C ulture and Depression Rauo W1UUn Groups Of Depressed Persons n =77 1 : 3 5 n = 23 1 : 4 3 n =25 1 : 3.4 n = 29 1 : 3 2 Percent wtihlh Groups Of Depressed Persons 28% 22% 25% 32% 189 Looking again at the population of 21 depressed persons 43 percent of them are British (Figu r e 5). The Euro Arnericans represent 33 percent of the total (n=21) while onl y 24 percent are Native Americans (Figures 4 and 6). These differences may not be significant in relationship to their representation in the total population (n=77) The Native Americans represent 31 percent, the Euro-Arnericans 33 percent and the British are 36 percent of the population (n=77). T hus establishing the significant differences in depre ss ion rates are greater than the five percent difference in population representation Marital Status, Languages Spoken Religion, Income and Depre ss ion The remaining variables of marital status, language s spoken r eligion, and income are not significantly correlated with the dependent variable of depre ssio n in the total population (n = 77) indicatin g no association (Tab le 10) Marital status has a stronger association with depression in the Native American population of r=0 37. It also has an insignificant negative correlation in the British (n=29) of r=-0 02 The Euro-American popu l ation (n = 25) also ha s a more significant negative relationship ofr=-0. 28

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190 There is a stronger negative association between depression and languages spoken of r=O.23 when the Guttman Technique is applied to the measurement of depression (Table 10). When the 3x3 table of depression dichotomized against three categories of religion is submitted to Chi-Square analysis the results reveal differences at p= < O .lO. The Guttman Technique The Guttman Scale Technique is used to test the unidimensiality of the Geriatric Depression Rating Scale (Short Form) This was done in an attempt to evaluate the cultural appropriateness of each item on the G D S (Short Form) for each specific culture A coefficient of reproducibility of r=O. 90 would indicate unidimensiality, meaning that the responses to items on the scale contribute to the ordering of persons and items in terms of depression For the total sample (n=77), from all three cultures and using all fifteen items, the coefficient of reproducibility is r=0 82 For the Euro-American population (n=25) it is r=0 80, for the Native American population (n=23), it is r=0 .83 and r=0.81 in the British population (n=29) (Table 15) Populations Total Population n =77 Euro-American n = 25 N ative American n = 23 Briti s h n-29 Table 15 Guttman Technique Co-efficients of Reproducibility C o-effic ient of Reprodu ci bili ty 0 .8 1 8 0.797 0 826 0 .8 14

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191 In order to clarify the relationship among the items of the Geriatric Rating Scale (Short Form) and further test the extent to which they contribute to a unitary factor "depression", factor analysis was done on the correlations of the 15 items that make up the G D S.. When the entire sample is viewed as a whole, Items 10 and 13R have little association with the other items on the G D S (Short Form) Item 10 has a low association of r=0 11, and item 13R has an association with the other items in factor I of r=O.l3. In the British population (n =29 ) alone items 17R and 13R have no association with the other items (Table 16) Items Loadings Facto r I Total (n =77) 11R 0 526 12 0.446 1 3 0 603 14 0.650 15R 0.332 16 0.478 17R 0.439 1 8 0 593 1 9 0 291 1 0 0 107 11R 0.418 12 0 .750 13R 0 127 14 0.614 15 0.459 Table 16 Guttman Technique Factor Analysis of the items of the Geriatric Depression Rating Scale and "Depression" Loadings Factor I Loadings Factor I Native American (n = 23) Euro-AmeriCilll (n-25) 0.000 0 .627 0 395 0.423 0 568 0 .670 0 793 0 .623 0.731 0. 197 0 000 0 .608 0 459 0 675 0 103 0 .637 0.450 0 177 -0 280 -0.190 O.o31 0.576 0 573 0 761 0.331 0 163 -0 055 0.765 -0 290 0 .340 Loadings Factor I British ( n =29) 0 .370 0 .260 0 539 0 .744 0.513 0.329 0.070 0.775 0.430 0.385 0 .337 0.811 -0.166 0 628 0 .706 Most significant is the lack of relationship in Factor I of Items 11R and 16 iri the Native American population at r=O.OOOO. Items 18 and 14 have no association and Item 10 has a negative association at r=-0.28. This lack of unidimensionality suggests the Geriatric Depression Rating Scale (Short Form) may not be a culturally appropriate instrument for this population (Table 16)

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192 The findings of the analysis of the Geriatric Depression Rating Scale (Short Form) using the Guttman Technique, strongly suggests that there is a lack of universal applicability of the G D S There is a need to develop an instrument with cultural sensitivity which would identify the presence and severity of depression Results Despite some measurement difficulties this study finds a degree of association demonstrated between the measured variables of (1) depression; (2) number of chronic illnesses; and (3) How many persons an individual resides with (social support) and ( 4) the number of friends' visits. Coefficients of correlation demonstrate these associations In the Native American population (n=23), the variables of age, chronic illnesses, workstatus medical costs marital status gender and visits from children and grandchildren have coefficients of association which are stronger than those for the other two culture groups There also exists a significant negative association with the number of visits from friends and also with whom they reside These relationships are distinctly more varied in each culture group than in the total population. In the British population (n=29) the presence of chronic illness has an association with depression Other variables with significant coefficients of association are the number of children and grandchildren and their visits There is a significant association with the number of individuals the respondent lives with indicating the more persons they live with the more depressed the individual

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193 Chronic lllness also has a correlation of association in the Euro-American population (n=25), further demonstrating the association of this variable in all three populations Medical costs are also associated with depression The strongest negative associations are the number of visits from friends and the gender of the respondents There is statistical evidence that the presence of chronic illnesses, lack of social support when living with others, and the infrequency of visits from friends and family are related to depression in the total population (n = 77) When the items from the Geriatric Depression Rating Scale (Short Form) are tweaked into a slightly more culturally appropriate scale for each culture, using the Guttman Technique there is further support for the association of these variables with depression (Table 10) The variables of (1) age ; (2) workstatus ; (3) medical costs; ( 4) gender; (5) culture; ( 6) number of children and their visits ; and (7) number of grandchildren and their visits are not significantly associated with depression in the total population (n = 77) They are howe ver sometimes more strongly related with depression when the populations are analyzed separately When each population is analyzed separately analysis reveals differences in the variables that have significant associations with depression. Depression in the British population (n=29), the most depressed, is more significantly associated with the variables of social support and number of children and family visits In the least depressed Native American (n = 23) population the presence of chronic illness and workstatus have greater associations with depression

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194 Although chronic illness and medical costs are associated with depression in the EuroAmerican population (n=25) the most significant negative association with depression is the gender of the respondent (females being less depressed) and the number of visits per week by friends In the total population, when depression is dichotomized against the three cultures the differences among the cells are significant at p=
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195 CHAPTER6 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS Discussion This study was done to improve our understanding of the associations among depression, chronic illnesses and culture in persons who are aging The research results indicate considerable evidence of an association of these variables with the presence of depression The analysis further identifies multiple variables and their effects on the presence of depression in older individuals This study of ethnicity and culture and the association with depression in older persons suggests interaction among the selected variables The variables analyzed in this study were selected because prior studies indicate they affect the mental status and presence of depression in older persons. The variables which are analyzed include : (1) Chronic Illnesses ; (2) Age ; (3) Culture!Ethnicity ; (4) Social Support which includes children ; (5) Marital Status and with whom the respondent resides; (6) Workstatus ; (7) Gender; (8) Education ; (9) Religion ; (10) Languages Spoken ; (11) Income ; and (12) Medical E x penses

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196 The Association of Chronic Illness With Depression Snowden (1990) indicates there is a much higher incidence of depression in older adults and they are frequently associated with physical symptoms which create "masked depression" (1990 : 141-145) The findings ofthis study concur with Snowden because of the empirical data which also indicates the incidence of depression is much greater in the population of individuals over age 55 than in reported rates in younger populations There is also evidence to support the need to evaluate older persons for the presence of minor depression which leads to twice the risk of developing disability than those who are not depressed (Blazer 1993b : 201) The number of illnesses an individuals developed, treated as a single variable, has the most influence on the development of depression in persons over fifty-five years of age. Chronic illness has a significant influence on the development of depression in all three populations representing three different cultures as indicated by this significant association of chronic illnesses and depression Among the most significant findings is the increase in the average number of illnesses in the total population (n=77) The Native Americans have the least amount of reported chronic illnesses in contrast to the Euro-Americans and British populations which each account for five percent more (Table 1). Ethnographic data support the findings that Native American respondents are healthier than the Euro-Americans and British.

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197 This association is relevant because the more illnesses an individual has the more likely they are to be depressed. Only five of the depressed persons (n=21) has less than two illnesses No depressed person reports being free of chronic illness. The most depressed persons, those who scored between 11 and 15 on the G.D S (Geriatric Depression Rating Scale), have an average of seven chronic illnesses (Table 9). All of the respondents from all three culture groups in this study indicate when they are ill their illness impacts their activities of daily living In depressed individuals this creates feelings of helplessness, hopelessness and worthlessness which are related to mood alteration and depression (Atchley 1994:142-144; Blazer 1993b:129135; Manson 1989:41) The non-depressed Native-American's perception of being "cured" promotes his/her acceptance of the chronic illnesses and the sense of well-being which influences continued participation in daily living The Relationship Between Age and Depression Previous research has shown that age has some influence upon depression, generally associating increasing age with depression (Baron et al. 1988; Blazer 1993b; Manson and Pambrun 1979; Stewart et al. 1989; Wells et al. 1989) In this study age is also moderately associated with depression in the Native American population (n=23) but has an insignificant association in the total population (n=77), the British (n=29) and the Euro-Americans (n=25) The results demonstrate cultural variations in the influences of age on depression.

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198 Life expectancy at birth in 1990 for the total population in the United States is 74.9, 78 3 for women and 71.5 for men (Atchley 1994 : 26-27) The seventies are the years when illness impacts the individual and they survive with chronic illness or they succumb and die. The aging process is most observable at this time and individuals frequently have social changes such as death of a spouse, relocation and multiple losses which have an impact. The Native American respondents present the belief that growing old and getting sick is part of living The respondents state they are not alone and others are available to them whenever they have needs such as going to the doctor, to meals or to shop They also are invited to activities and are an integral part of activities on the Pueblo. Respondents from the British population relate that they are taken to health care facilities by transportation provided by the health service They also have health visitors and caretakers in their retirement schemes Many indicate they do not see their families very often New friends are acquired in their living areas but they do not see old friends very often or participate in activities in their communities. The Relationship Between Culture and Depression Holstein and Cole (1996) present the importance of integration of the culture of biomedicine and individual meaning They state that "chronic illness challenges forms and frameworks of meaning that are difficult to reconfigure given prevailing images of old age" (1996 : 7)

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199 The culture of an individual detennines to a large extent attitudes toward aging and the acceptance of the aging process. Culture detennines where people reside and with whom they depend for support There are developed community patterns of socialization which exclude the elderly There are also patterns of provision of services for the elderly which are part of the formal network in all three cultures which were studied The informal network exists in the three cultures but is most developed in the Native American culture in the Pueblo. There are family networks that support the needs of aging individuals in all of the cultures studied, but the Native American population has the strongest ties with the extended family Their residential patterns also enhance the ability to support the elderly in their community The British culture has the weakest ties in the extended family They rely on a highly funded and highly developed formal network of health and social services to help meet the needs of the elderly There are considerable deficits in the provision of social interaction and support from the extended families There is a deficit which is exhibited in the loneliness related by the British respondents The Euro-Americans in Central Florida have more interaction with the extended families and more individuals live with their children They have a fragmented formal network which provides for their needs however they have a more integrated family network. The Euro-American respondents believe they are more optimistic and involved as aging individuals when they remain healthy When they develop chronic illnesses they feel helpless and their well-being is threatened and indicate they feel worthless.

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200 The Relationship Between Social Support Variables and Depression The variables of social support have empirical associations with the presence of depression The variables studied have been identified in the literature as being sociocultural factors which affect the mood and mental status of individuals (Blazer 1993b; Manson 1989 ; Wells et al. 1989 ; Atchley 1994) They have also been specifically identified as important factors which affect the well-being and mood of aging individuals This resear c h further supports the importance the relationship of the identified variables through this ethnographic study while giving empirical evidence of statistical associations of identified variables Living with other individuals has a modest correlation with depression The least depressed population, the Native Americans, live with the fewest persons however they live on the Pueblo near more children and grandchildren There is, however a statistically high correlation betw e en the number of persons an individual resides with and the presence of depression in the British population. They have the fewest children and visits from the family and are the most depressed This relationship between depression and the numbers of persons a British respondent lives with may be associated with their dependency in assisted living centers and there is a need to further study this observation The variable "with whom the respondent resides is significantly related to depression in the British population (n = 29), and may influence the presence of depression, while the relationship is weaker in the Euro-Americans (n=25) and Native Americans (n=23)

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201 It must be noted that more Euro-Americans reside with family members and Native Americans live in proximity to more family and friends on the reservation, while the British frequently live in retirement centers with many persons Marital status is also an important variable in social support Of the individuals who are married all live with their spouses The British who are the most depressed population, have the fewest married persons with more individuals living alone (Tables 2 and 3). In the depressed population (n=21) one fourth ofthe respondents live alone The number of children, number of grandchildren, and the frequency of their visits are not highly correlated with depression in the total population (n = 77) but there is significance in the association between the number of children and the presence of depression in the British population This also demonstrates that cultural variation has significance in relationships of these select e d variables and depression in this population (n=29), since the associations are greater The identified variables indicative of social support are correlated with depression (Table 1 0) These variables are also associated with the presence of individuals who may be supportive reducing feelings of helplessness and hopelessness and thus reducing depression The Relationship ofWorkstatus With Depression The workstatus of individuals is a significant variable wh e n culture groups are analyzed separately

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202 The Native Americans have the greatest number of persons who are actively involved in an avocation and they have the only moderate correlation with workstatus and depression. The British who are the most depressed culture group did not have any individuals who are involved in work or avocation although they are involved in hobbies and care taking. The Euro-Americans have the largest number of persons who continue to work, 20 percent of the respondents (n=25) These populations do not show significant associations between the variables of workstatus and depression. There are cultural differences in the perception of work and differences in the application of avocations after retirement. In all populations individuals who accept aging and retirement often plan to pursue their interests for the pleasure they get from the activity Others plan on making an income from a pursuit they find interesting and rewarding These differences are evident in the ethnographic information reported in Chapter 4 The total British population of respondents is totally retired They do not work and earn no income other than their retirement benefits In contrast four Euro-Americans remain in the workforce and one is involved in an avocation. No individual who remains working is depressed. Although the quantitative data do not suggest a strong relationship to depression, involvement in productive activity is worth further study since none of the depressed individuals are actively working

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203 The Relationship Between Depression and Gender The gender of individuals in the total population (n=77) has almost no association with depression, but the difference between the percentage of depressed males and depressed females in the total population shows the males being more depressed. The depressed males have more chronic illnesses than the depressed females, although females who are depressed do have chronic illnesses These findings are significant and further study is recommended There is evidence of an overlap of the variables of chronic illness, gender and the development of depression There is further need to understand this finding because it has been reported that females have more incidence of depression and symptoms of dysphoria than males in the general population (Haber et al. 1982:534; Diagnostic and Statistical Manual IV 1994c). It is also noted that age is positively correlated with depression but there is a need for further research to better understand the increasing incidence of depression in aging men (Haber et al. 1982 : 534). I would also recommend that studies be carried out with respondents who would be able to give insight into the cultural variables that affect their mental status in later life development but were not operative during their younger developmental phases. The male respondents generally did not present with affects which indicated they are depressed The females were more willing to talk about their feelings and express sadness and dysphoric feelings The Geriatric Depression Rating Scale (1987 Short Form) was the instrument used to ascertain the presence of depression

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204 There are reports that cultural factors related to gender differences affect expression of emotions related to feelings of depression (Bakal 1979 : 11 0; Haber et al. 1982 ; Blazer 1993b:15) The subordinate role ofwomen in Western culture occurred as a result of the development of the state and patriarchal rule and law (Bleier 1984 : 159). Karen Sachs (1979: 6) enlightens us with the empirical knowledge that women are not universally subordinate or dependent. There is space for role reversal and change to occur in families and society Men are also affected by changes which reduce their power, control, and responsibility Learned helplessness has been associated with depression (Bakal 1979: 121) Learned helplessness is associated with behavioral passivity which is reinforced (Seligman 197 4 : 121) Depression may also be related to a perception of an individual s loss of control of the environment (Bakal 1979 : 123) The combined factors of presence of multiple chronic illnesses, inability to control their environment, loss of meaningful activity, and role reversal offer further insight as to why significantly more men are depressed as compared with women Blazer (1993b: 19) also suggests that the dramatic increase in rates of depression in the total population in the late twentieth century are best explained by psycho social factors

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205 Depression and the Association with Education Education does not have a statistically significant association with depression, although it does have an infinitesimally small negative correlation in the total population (n=77) In preliminary studies there was found to be a stronger negative correlation which suggested the greater the education the less probability the individual has of being depressed The probable reason for no significant statistical association in the current sample is the relative uniformity in the educational level of individuals in all three populations The depressed individuals are not significantly either more or less educated. The presence of the negative correlation in the earlier study suggests however that there is need for further study related to the lack of education and the likelihood of increased depression. Medical Costs and the Association with Depression Medical costs do not have a significant statistical association m the total population (n=77) In contrast, medical costs are more significant in the relationship with depression in each population when measured separately In the Native American (n=23) and Euro-American (n=25) populations there is an association with depression In the British population (n=29) there is no association with depression and these findings are probably related to the fact the British have no medical costs associated with their illnesses while the Native Americans and the Euro-Americans do

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206 This finding could be further studied between populations in the United States which might give insight into the observed association between the variables of medical costs and depression Depression and Its Lack of Association with the Variables of Religion, Languages. and Income The observed variables which do not have a significant association with the presence of depression in older persons are religion, languages spoken, and income There is statistical evidence of no associations in the total population (n=77) The ethnographic information reveals that individuals in all three cultures have varying degrees of acceptance of their identified religions Many state they do not participate in their religion but belong to their religious affiliation There are many reasons for their lack of participation Respondents often state they do not agree with their religious leaders may not be able to attend regularly or may not wish to participate It is also noteworthy that all of the Native Americans identified themselves as being Roman Catholic with seven individuals who said that they classify their ethnicity or culture as a religion Most of the British report being Protestant and belonging to the Church of England with one individual being Jewish The Euro-Americans are the most diverse representing the Catholic Protestant and Jewish religions The variation is not significant enough to affect the presence of depression in the population studied

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207 Languages spoken and income have no statistical associations with the presence of depression in all populations studied These variables are not necessary to include since there are no indicators from ethnographic data suggesting they influence well-being Conclusions Perhaps the most important general finding is that when each population is analyzed separately correlations between depression and the several variables studied vary from those that are found when these three samples are treated as one universe In the Native American population (n=23) ; age, chronic illness, workstatus medical costs, visits by children, visits by friends marital status and gender have the most significant association with depression measured by the Geriatric Depression Rating Scale (Short Form) This population is the least depressed of the three populations and more (9) of the seventeen variables are associated with depression This differs in the British with six and five for the Euro-Americans (Table 1 0) The most depressed population, the British (n=29), shows a significant negative association between social support and depression These include social support factors; (1) the number of persons with whom the individual resides ; (2) the number of children and grandchildren ; and (3) the frequency of their visits. Depression is also shown to be associated with the presence of chronic illness in this population (Table 1 0)

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208 In the Euro-American population (n-25) the most significant negative association is between depression and gender with men being more depressed than women There is also a very significant negative association between depression and number of visits per week by friends indicating the more visits the less depression experienced by individuals The presence of chronic illness and related medical costs are also associated with depression in this population of respondents (Table 10) When the three populations are treated as one the findings reveal that depression as measured by the Geriatric Depression Rating Scale (Short Form) is significantly related to (1) the number of chronic illnesses; (2) the increasing number of individuals they reside with and (3) the frequency of friends visits. While the findings support the relationship between depression, the presence of chronic illness, and the social support aging individuals experience, a major finding is that culture variations seems to med i ate the relationship between aging, chronic illness and depression There are indications that some cultures offer lifeways which prevent depression The items that make up the depression scale (G.D.S.) itself give evidence of cultural relativism when interrelations among the items are analyzed The analysis of the relationships among the several items that make up the Geriatric Depression Rating Scale (Short Form) indicates that the scale may contain a lot of "noise" Attempts to measure the unidimensionality using the Guttman Technique reveal a coefficient of reproducibility well below r=0.90, the value that tends to be accepted for unidimensionality. This suggests a scale containing factors that vary independently of what we are trying to measure, namely, depression.

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209 To improve its stability, one would have to remove several items, namely 10 and 13, but even then the coefficient of reproducibility does not reach the optimal threshold for a unidimensional scale, but does increase to r=0 .81 in the total population (n=77). When this technique is applied for each population separately, the separate coefficients of reproducibility still remain below r=0 90 but different items contribute to that error rate It is evident that the G D .S. is not the optimal instrument to measure depression when cultures vary Since previous validity and reliability have been established by Sheikh and Y esavage (1986b ) the significant difference in validity is its use in three ethnically distinct cultures for this study. Since unidimensionality is not established, other factors may influence the results When the unrelated items on the G D S were adjusted usmg the Guttman Technique depression thus measured with the other variables reveals a more universal relationship when the three cultures are treated as one (n=77) The variables of (1) the number of chronic illnesses ; (2) the number of persons an individual lives with; and (3) the frequency of friends visits remain significant. This study is valuable because of the interdisciplinary integration of anthropology, gerontology, and health in order to better understand the relationship of the variables studied lifeways, and depression. There is an opportunity to inte g rate the cultural context of relationships and also to understand how this affects older persons

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210 Recommendations The findings of this study affirm that higher rates of depression in the aging population seem to be cross-cultural phenomena. The lifeways which affect each cultural group vary in their relationships with depression. There is a need to integrate cultural meaning into the aging process. This also would enlarge the meaning of old age and allow individuals to stop thinking dichotomously about independence and dependence, the body and the spirit, freedom and coercion, and science and religion (Holstein and Cole 1996:20). It seems from the data previously presented, that the key to prevention of depression in the aging population is the fostering of interdependence in a lifetime There is a need to integrate cultural lifeways which offer understanding of meaning, value, and wisdom Furthermore there is also a need to include the philosophical-spiritual aspects of life in the process of living These elements of culture need to be integrated into the development -of a culturally sensitive depression rating scale. There is importance in the integration of the culture of biomedicine and individual meaning. As previously stated, the chronically ill elderly often feel devalued, discredited and socially isolated There is a need to further integrate this research with other findings that establish diagnostic criteria related to culture as necessary for appropriate intervention and treatment. This integration is most necessary in the Diagnostic and Statistical Manual IV ( 1994c) which is used for psychiatric diagnosis

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211 Given the level of concern expressed by The World Health Organization and The World Bank about the aging of the world populations that there is a need to prepare for the "onslaught of chronic conditions (Murray 1996) and that disability caused mental illnesses led by depression --will be the second worst scourge by 2020, trailing only heart disease (Murray 1996) -the present study makes the following recommendations to those other global policy makers : (1) To better understand the relationship of the variables studied, lifeways and depression, seize the opportunity to take into account the cultural context of relationships ; (2) To better understand the cultural lifeways which offer understanding of meaning value and wisdom, do more research into the philosophical-spiritual aspects of life and develop more culturally sensitive depression rating scales; and (3) To prevent as much depress i on as possible exert the effort to include culturally meaningful ideas and values into prevention policies leading into culturally appropriate preventive measures

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233 Troll, Lillian E., Sheila J. Miller and Robert C Atchley 1979 Families in Later Life Belmont California : Wadsworth United States National Center for Health Statistics ; Vital Statistics of the United States Annual & Unpublished Data 1995 : 92-96 1993 Table 186 Washington : United States Printing Office United States Bureau of Census 1985a Washington, D C.: United States Government Printing Office 1990b Washington, D C.: United States Government Printing Office United States Postal Service Lakeland Division 1995 Marketview Comparison Report Arlington Va.: Claritas United States Senate Special Committee on Aging 1976 Developments in Aging : 1975 and January-May 1976 A Report Resolution Authorizing a Study of the Problems of the Aged and Aging Together with Minority View, Part I and II. Washington D C : U.S Government Printing Office University ofFlorida 1995 Florida Statistical Abstracts Gainesville : University ofFlorida Bureau of Economic and Business Van Gennep, A. 1960 The Rights ofPassage Chicago : University of Chicago Press Vega W., G Warheit, and J. Buhl Auth 1984 The Prevalence ofDepressive Symptoms among Mexican-Americans and Anglos Journal ofEpidemiology 120 : 592-607 Waern, U. 1978 Health and Disease at the Age of Sixty. Findings in a health survey of 60 year old men in Uppsala and a comparison with men ten years younger. Uppsala : Journal ofMedical Sciences Wattis John, Libby Wattis and Tom Arie 1981 Psycho-Geriatrics : a national survey of a new branch of psychiatry. British Medical Journal282: 1529-1533 Waxman, Howard M et al. 1985 A Comparison of Somatic Complaints Among Depressed and Non Depressed Older Persons The Gerontologist 25 : 5 501-508

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234 Weale, Robert D 1985 What is Normal Aging Part XI : The eyes of the elderly Geriatric Medicine Today Vol. 4(3) : 29-37 Weidman Hazel H 1978 Miami Health Ecology Project Report : A Statement ofEthnic Health Miami : University ofMiami School ofMedicine Weiss I K. C L. Nagel and M K. Aronson 1986 Applicability ofDepression Scales to the Old Person Journal of the American Geriatrics Society 34 : 215-218 Wells, Kenneth B. 1989 The Functioning and Well-Being ofDepressed Patients: Results from the medical outcome study. Journal of the American Medical Association 262(7): 914-919. Wenke Robert J. 1981 Explaining the Evidence of Cultural Complexity: A review. Advances in Archaeological Method and Theory 4 : 79-127. In Native North Americans: An ethnohistorical approach, Boxberger and Daniel, eds. Pp. 11. Dubuque, Iowa: Kendell/Hunt Pub White, Geoffrey M 1994 Ethnopsychology In New Directions in Psychological Anthropology Theodore Schwartz, Geoffrey M White and Catherine A Lutz, eds ,. Cambridge: Cambridge University Press White Leslie 1949 The Science of Culture New York: New York. Whitman William 1947 The Pueblo of San Ildefonso New York : Columbia University Press. Wike, Joyce 1941 Modem Spirit Dancing ofNorthe m Puget Sound M A. Thesis in Anthropology Seattle : University of Washington Willey Gordon R. 1966 An Introduction to American Archaeology Englewood Cliffs : Prentice Hall, Inc

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235 Wierzbicka A 1991 Cultural Models ofHealth and Illness : Proposals from ethnographic research A report to the Committee on Survey Methods Research, United States Bureau of the Census : Joseph and Shweder, eds Chicago : University of Chicago Wolinsky, Frederic D 1992 The Sociology ofHealth : Principles practitioners and issues 2nd Edition Belmont, CA. : Wadsworth Publishing Company Woodward C Vann 1971 Origins of the New South 18771 913 T exas : The Louisiana State University Press and the Littlefield fund for Southern History and the University of Texas Y esavage, J.A. et al 1982-1 983 Development and Validation of a Geriatric Depress ion Rating Scale J oumal of Psychiatric Research 1 7: 3 7

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236 APPENDIX I: AGE, ILLNESS, DEPRESSION ETHNICITY Q1J ESTIO NN AIRE

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237 APPENDIX 1: AIDE QUESTIONNAIRE ADDRESS OF RESIDENCE ___________ GENDER M F MARITAL STATUS: M ----------------------------------s D W What is your Race? Where did -------------------------------------------------your ancestors come from? -------------------------------Where were you born? ____________________________________________ How do you identify your national heritage? 1 Do y o u have chi 1 dren ? __________________________ __ ___________ __ 2 How rna n y children do you have? ________________________ __ __ __ 3 Do you have g r a ndc hi 1 d r en 7 _____ __ __ __ __________________ __ __ __ 4. How many grandchildren do you have? ______________________ 5. How often do you see your children? DArLY ______________ __ YEARLY -----------WEEKLY OTHER ------------------------MONTHLY ---------------6. How often do you see your grandchildren? DAILY YEARLY -----------------------MONTHLY _____________ OTHER -----------WEEKLY ______________ ___

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APPENDIX I : CONTINUED 238 7. What was the last grade you completed in school? -------8 What did_you study? __________________________ -=--------------9. Where did you attend school? 1 0 What did you do to earn a living? ______________ __ 11. you retired? _________________________ __ 2. Whe n d.i.d you retire? _____________________ __ 1 3 Do you do anything related to your work at the present time? 1 4. Do you consider your expenses to be great? ________ 15. Please describe the expenses related to your health or illnesses ---------------------------------1 6 H o w often do you see you r friend or friends? _____ M O N T HLY _____ ___ __ WEEKLY ____ __ OTIIER 1 7 Who do you live with? ---------------------18. I s Your income between: $ 5,000-1 5,000 ________ __ 36,000-50,000 -------16,000-25,000 ______ __ 50,000-65,000 _______ 26,000-35,000 _______ __ above 65,000 --------

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239 APPENDIX II : ILLNESS LIST (OARS)

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APPENDIX ll I Co you have any of the at the tlme7 (CHECK "YES" OR "110" fOR EACII Of THE fOLLOWitiG. If "YES," ASK: Ho"' muc h it interfere your actlvltles, not at all, 240 a little or a great deal7" AND CHECK TilE i\PPROPRii\TE BOX. l ... -Great Yes No N o t At 1\11 ... Little Deal -, I I Arthritis or rheumatism Glaucoma A11thma Emphysema or chronic bronchitis Tuberculosis High blood pre11aure Heart trouble Circulation trouble in arms or legs Dlabete9 Ulcers ( of the digestive system) Other stomach or Intestinal disorders or gall bladder problems Liver Kidney Other urinary tract disorders (incl. prostate trouble) Cancer or leukemia Anemia Ettect ot ---'-"'e::Jral Hultiple Huscular dystrophy Effects of polio Thyroid or other glandular disorders Skin disorders such aa pressure sores, leg ulcers or severe burna Speech impediment or Impairment

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2-+1 APPENDIX ill: GERIATRIC DEPRESSION RATING SCALE (SHORT FORM)

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GERIATRIC DEPRESSION SCALE {Short Form) CIRCLE THE BEST ANSWER FOR HOW YOU FELT OVER THE PAST WEEK Are you basically satisfied with your life? Have you dropped many of your activities and intereSlS? Do you feel that your life is empty? Do you often get bored? _1\re you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things Do you feel that you have more problems with memory than most? Do you think that it is wonderful to be alive now? D
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GERJA TR1C DEPRESSION SCALE SCORES {Shon Form} THIS IS TilE SCORING fOR THE SCALE. ONE POINT FOR EACH OF THESE ANSWERS. CUT OFF NORMAL 10-5). ABOVE 5 SUGGESTS DEPRESSION. 1. NO 6. YES 11. NO 2. YES 7. NO 12. YES 3. YES 8. YES 13. NO 4. YES 9. YES 14. YES 5 NO 10. YES 15. YES

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IV: BLOCH'S ETill,riC/CUL TlTRAL ASSESSi\1ENT GUIDE

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APPENDIX IV Categories Cultural Ethnic origin fiace Place ot. birth Relocations Habits, custo1111, value!!, and beliefs BLOCH'S ETHNIC/CULTURAL ASSESSAENT GUIDE Data collected 245

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APPENDIX IV CONTINUED Categorit!s Behaviors valued by culture Cultural sanctions and restrictions Language and communication Language(!!) and/or dialect(!!) spoken D
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APPENDIX IV CONTINUED Categorte:s Language barri
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APPENDIX I V CONTINUED Cultural health beltefs Cultural healers Nutritional variables or !act-ors Data collected 248

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APPENDIX I V Categories Characteristics o f food pri!paratiori and coneumptio n Intluencee troll external environment Patient education need!J Data collected 249

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APPENDIX IV CONTIN UED Peychological Self-concept (identity) !!ental and and or ethnic/ cultural group Data collected 250

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APPENDIX IV CONTINUED CONTlNUED Sociological Economic etatus Educational status Social ae eupportive group Data collected 251

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APPENDIX IV CONTINUED Categories Supportive in ethnic/cultural community Data collected 252

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APPENDIX IV CONTINUED Categories Religious influences on psychological effects of health/ illness Psychological/cultural response to stress and discomfort of illness, Data collected 253

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254 APPENDIXV : PATIENT CONSENT FORM

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Al'PENDIXV STIJDY: ADV1SOR: Investiga tor's Statement: CONSENT FOR.lVl Investigation of individuals perceived indicators of presence of chronic illnesses and mood in relationship to their age and culture. Rosemarie S. Lamm. Doctoral Candidate Department of Applied Anthropology University of South Florida Home Phone No.: 941-646-2452 Work Phone No.: 941 688-8583 Alvin W. Wolfe. PH.D. Professor. Department of Applied Anthropology University of South Florida Phone No.: 9419740794 255 1 am interested in obtaining information about how aging. the presence of chronic illness. and culture may affect the mood of individuals. Aging often creates changes which include physical. psychological, and social adaptation. Learning more about the relationships among these variables might be useful in improving the quality of lite for aging individuals. 1 am requesting your voluntary consent to participate in the study. There will be no financial cost associated with your participation. If you agree to participate. you will be asked to complete three short questionnaires. and consent to one scheduled interview. The total rime for your participation will be about one hour. 1 will be present when you fill in the questionnaire, and 1 will be the indivdual who will ask you the questions. Instructions will be given verbally and a cover sheet on the questionnaire will also give instructions which are not campier. Your participation is voluntary and your identity will be kept confidential. Your responses to the questionnaires will not be part of any medical. social or psychological record. Research results may be requested by any individual who participates in the study. and I will make the results available. The results of this study will improve the understanding of the unique relationship between aging. chronic illness. mood and culture and improve the quality of life. If you agree to participate, please sign copies of this lener and keep one copy for yourself Thank you for your time and participation. Subjecfs Statement 1 voluntarily consent to participate in this study, and give consent to use the questionnaires as needed for this study. 1 understand that 1 have an opportunity to ask questions, and can withdraw from this study by informing the investigator. 1 understand that this study may no t benefit me personally. but may help persons who are affected by changes related to the aging process. Subjecfs Signature Signature of Investigator Date Date

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256 Vita Rosemarie Santora Lamm earned her Diploma as a Registered Nurse from the Buffalo General Hospital and the University ofBuffalo in 1960 She began her career in nursing in medical-surgical, emergency room, and operating room specializations She completed the Bachelor of Arts degree at St. Leo College with majors in social science and psychology and graduated Summa Cum Laude in 1976 She completed the Master of Arts degree at the Uni v ersity of South Florida in Gerontology in 1977 Rosemarie returned in 1988 to earn the Master s of Science in Nursing in 1990 and entered the Ph. D program in Applied Anthropology in 1991 While accompli s hing educational g oals Rosemarie directed a mental health department at Peace River Center and began her teaching career at St. Leo College in 1976 She went on to teach and develop curriculum at F l orida Southern College from 1979 to 1 99 5 She also developed Creative C oun s eling Center and is the first Nurse Practitioner in private practice in Polk County As a member she has presented numerous papers at the Gerontological Society of America the Society for Applied Anthropology the Southern Gerontological Society and the Florida Nurse s Association