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ORIGINAL ARTICLES |
From the Departments of Epidemiology and Biostatistics (F.C.B., N.A.) and Clinical and Health Psychology (D.B.P.), College of Public Health and Health Professions, University of Florida, Gainesville, Florida; Department of Public Health Sciences (A.A.A.), University of North Carolina at Charlotte, North Carolina; and the Center for Sexual Health Promotion (B.D.), Department of Applied Health Science, Indiana University, Bloomington, Indiana.
Address correspondence and reprint requests to Deidre B. Pereira, Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, P. O. Box 100165, Gainesville, FL 32610-0165. E-mail: dpereira{at}phhp.ufl.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Methods: We obtained 2004 BRFSS demographic, asthma, and mental health data on Hispanics, non-Hispanic Whites, and non-Hispanic Blacks. Linear regression analysis was used to examine the main and interaction effects of race/ethnicity, income, and history of asthma on poor mental health (n = 282,011), as well as on depression (n = 14,907) and anxiety (n = 14,871) specifically.
Results: A significant three-way interaction emerged among race/ethnicity, income, and history of chronic asthma on number of days of poor mental health. Among the most impoverished (income <$15,000/yr), Hispanics with asthma reported greater number of days of poor mental health than non-Hispanic Whites with asthma. However, among those with slightly greater economic resources, Hispanics with asthma reported fewer number of days of poor mental health than non-Hispanic Whites.
Conclusions: The results of this study highlight the complex interactions among race/ethnicity, income, and asthma on mental health outcomes.
Key Words: asthma • income • racial minorities • ethnic minorities • mental health
Abbreviations: BRFSS = Behavioral Risk Factor Surveillance System.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Past studies have found that these racial and ethnic disparities in asthma rates may be explained by socioeconomic status (2,3); however, these findings have been controversial. A recent cross-sectional study (3) that utilized the 1997 National Health Interview Survey database revealed that non-Hispanic Black children had a greater prevalence of asthma than non-Hispanic White children, but only for those with lower socioeconomic statuses. This research suggests that exposure to social and environmental risk factors for asthma may overshadow any possible genetic risks.
Racial and ethnic disparities also exist in the prevalence of mental disorders, although findings have been inconsistent. The Epidemiological Catchment Area Studies (4) demonstrated that, regardless of race, Hispanics and non-Hispanics were found to have similar rates of mental disorders; however, among non-Hispanics, Blacks were found to have a greater risk for mental disorders than Whites. On the other hand, The National Comorbidity Study (5) found that Hispanics are at greater risk for affective disorders than non-Hispanic Whites, with Hispanic rates almost twice that of Whites. It has been posited that racial and ethnic minorities may experience a different rate of mental disorders due to the effects of discrimination and low socioeconomic status on mental health (4,6,7). In a recent international study by the World Health Organization’s International Consortium in Psychiatric Epidemiology (8), it was found that greater socioeconomic disadvantage (such as low income and education and unemployment) was related to the greater occurrence of mental disorders, including affective disorders.
Some research suggests that pulmonary disease, such as asthma, is frequently comorbid with mood and anxiety disorders. Brenes (9) noted that anxiety disorders, especially panic disorder and generalized anxiety disorder, frequently co-occur with chronic obstructive pulmonary disease. Bowen, Senthiselvan, and Barale (10) found that risk for anxiety disorders was significantly increased in individuals with respiratory as well as other diseases. Although the exact direction of the relationship between respiratory disease and mood impairment is unclear, there is some suggestion that respiratory disease may predispose individuals to some mental health disorders, such as panic disorder (11), and may predict the onset of both anxiety and depression (12).
Although research has uncovered racial and ethnic disparities in both rates of chronic asthma and mental illness, as well as associations between chronic asthma and mental illness, no published research to our knowledge has examined whether racial and ethnic disparities in chronic asthma are associated with mental health outcomes. The purpose of the present study was to examine the relationships among race/ethnicity, income, and history of chronic asthma on mental health outcomes in individuals surveyed as part of the 2004 Behavioral Risk Factor Surveillance System (BRFSS) (13). We hypothesized the following: a) a history of chronic asthma would be associated with poorer mental health outcomes and this relationship would be modified by race/ethnicity (i.e., non-Hispanic Blacks and Hispanics with a history of asthma would have poorer mental health outcomes than non-Hispanic Whites), and b) the relationship between race/ethnicity*history of chronic asthma and mental health outcomes would be further modified by income (e.g., the relationships in b) would be especially pronounced for those of low socioeconomic status).
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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18 years. Data were collected by home telephone calls by interviewers. Details of the plan, sampling, operation, and response have been published, as have procedures used to obtain informed consent and to maintain confidentiality of information obtained (13). The survey is conducted by all 50 states and the District of Columbia, as well as by the US Virgin Islands, Puerto Rico, and Guam. Public health officials use this survey to develop health policy by computing prevalence rates and establishing relationships among variables. Permission to use the 2004 BRFSS database was obtained from the Centers for Disease Control and Prevention and this study was approved by the University of Florida Institutional Review Board. All of the above states/territories participated in the 2004 survey with the exception of Hawaii and Guam. The 2004 BRFSS questionnaire (available at http://www.cdc.gov/BRFSS/questionnaires/pdf-ques/2004brfss.pdf) was comprised of 21 core modules on demographics, health status, and health-related behaviors. All participating states/territories were required to ask all of the core module questions without modification. The 2004 BRFSS also contained 20 optional modules. Participating states/territories were allowed to administer none, some, or all of the optional modules. However, if a particular optional module was administered, all questions in that module were required to be asked without modification. The number of records in the entire 2004 BRFSS database was 303,821.
In the present study, questions from the following Core Sections were used: Asthma (Core Module 9), Healthy Days—Health Related Quality of Life (Core Module 2), Demographics (Core Module 13), and Tobacco Use (Core Module 7). In addition, questions from the following Optional Section were used: Healthy Days (Symptoms) (Optional Module 5). In 2004, the following States elected to ask questions from Optional Module 5: Hawaii, New York, Rhode Island, and South Carolina.
Assessment of Independent Variables
History of Asthma (Core Module 9)
BRFSS participants were asked, "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" Individuals answering "Yes" to this question were classified as having a history of asthma. This question has been used widely by public health officials to assess lifetime asthma rates at the state (14) and national levels (15–17). Previous research has used this item to assess the relationship between asthma and race/ethnicity (16,18), quality of life (19), and risk factors for asthma (15).
Race/Ethnicity (Core Module 13)
Participants were asked whether they were of Hispanic or Latino ethnicity and were then asked to identify the group that best represented their race: White, Black, Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaskan Native, or Other. Responses on these two items were then used to categorize race/ethnicity for the purposes of the present study. Specifically, analyses for the present study were limited to individuals falling within one of the following racial/ethnic groups: White only, non-Hispanic; Black only, non-Hispanic; and Hispanic (of any race). Non-Hispanic individuals of any race other than White or Black were excluded from the present analyses.
Income (Core Module 13)
Among other demographic questions contained in Core Section 13, BRFSS participants were asked to report their annual income. The ranges of income were <$15,000; $15,000 to $24,999; $25,000 to $34,999; $35,000 to $49,999; and $50,000.
Assessment of Covariates
Gender, age, and cigarette smoking were used as covariates. To assess cigarette use (Core Module 7), "Tobacco Use", the BRFSS asked the following questions: "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Responses on these items were then used to categorize participants into one of the following four categories: current smoker—smokes every day; current smoker—smokes some days; former smoker; or never smoked.
Assessment of Outcome Variables
Mental Health (Core Module 2, Optional Module 5)
Overall mental health was assessed in Core Section 2. Specifically, participants were asked to estimate the number of days they experienced poor mental health in the past 30 days. The following question was used: "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?"
In addition, BRFSS respondents in states that administered Optional Module 5 were asked additional questions about their experience with depression and anxiety. Specifically, to assess depressive symptomatology, participants were asked, "During the past 30 days, for about how many days have you felt sad, blue, or depressed?" Anxiety was assessed with the following question: "During the past 30 days, for about how many days have you felt worried, tense, or anxious?"
These items have been used by state officials to assess anxiety, depression, and mental health within states (20,21) as well as by public health officials to assess anxiety, depression and mental health at the national level (6,7,22,23). Previous researchers have used these assessments to correlate self-reported anxiety, depression, and mental health with social functioning (23), chronic disease (19,23–25), disaster (26), war (27), behaviors risky to health (e.g., smoking and drinking) (22,28,29), access to health care (26), demographics (20), and overall physical health (23).
Statistical Analyses
SAS version 9.1.3 (SAS Institute, Inc., Cary, NC) was used for all statistical analyses. Linear models were fit using PROC SURVEYREG, which accounts for the complex survey design of the BRFSS. Main effects of asthma, race, and income were computed, adjusting for age, gender, and smoking status. An interaction term between race/ethnicity and asthma was computed and fit into a model. In a second model, an interaction between income and asthma was computed and a three-way interaction among race/ethnicity, income and asthma was computed. When the three-way interaction was significant, post hoc analyses were conducted by computing a race/ethnicity*asthma interaction at each income level using the SAS macro %SREGSUB. Descriptive statistics were performed with PROC SURVEYMEANS and PROCSURVEYFREQ to calculate weighted means and percentages.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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3 select demographic factors) or complete data were included in the present study. Of these 286,738 participants, 73.94% were non-Hispanic White, 10.39% were non-Hispanic Black, and 15.65% were Hispanic of any race. The mean (Median) number of days of poor mental health (n = 282,011), depression (n = 14,907), and anxiety (n = 14,871) experienced in the prior 30 days was 3.42 (0.00), 3.14 (0.00), and 5.00 (1.00), respectively (Table 1). The distribution of values on these mental health outcomes were both leptokurtic and positively skewed. Although the assumption of normality was violated, linear regression analysis was used, as this test is robust to violations of the normality assumption with large sample sizes.
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Covariates and Mental Health Outcomes
Women, daily smokers, and individuals <65 years of age reported significantly greater number of days of poor mental health and anxiety symptoms compared with their counterparts. Women and daily smokers also reported significantly greater number of days of depressive symptoms; however, age was not associated with number of days of depressive symptoms (Table 2).
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Mental Health Outcomes by Race/Ethnicity and Asthma
Poor Mental Health
There were significant main effects for race/ethnicity and history of asthma on number of days of poor mental health. Both non-Hispanic Blacks and Hispanics reported significantly greater number of days of poor mental health compared with non-Hispanic Whites. Furthermore, individuals with a history of asthma reported a significantly greater number of days of poor mental health. However, a significant race/ethnicity*asthma interaction did not emerge (Table 2).
Depressive Symptoms
In addition, there were significant main effects for both race/ethnicity and asthma on the number of days of depressive symptoms as well as a marginally significant race/ethnicity* asthma interaction (p = .0587). Post hoc analysis of this trend revealed that among individuals with asthma, Hispanics, but not non-Hispanic Blacks, reported a significantly greater number of days of depressive symptoms than non-Hispanic Whites (Table 2).
Anxiety Symptoms
There was a significant main effect for asthma, but not for race/ethnicity, on the number of days of anxiety symptoms, such that individuals with a history of asthma reported significantly greater number of days of anxiety symptoms. A race/ethnicity*asthma interaction on anxiety symptoms did not emerge (Table 2).
Mental Health Outcomes by Race/Ethnicity, Asthma, and Income
Poor Mental Health
There was a significant main effect for income on the number of days of poor mental health, and this main effect was modified by history of asthma. Among individuals with a history of asthma, those with an income of <$50,000 per year reported significantly greater number of days of poor mental health than those within with an income of $50,000 per year (Table 3). In addition, a significant three-way interaction among race/ethnicity, income, and asthma on poor mental health emerged. Post hoc analysis revealed significant race/ethnicity*asthma effects on poor mental health for individuals with an income of <$15,000 per year and those with an income of $25,000 to $34,999 per year. Specifically, among the most impoverished (i.e., income of <$15,000 per year), Hispanics with asthma reported a significantly greater number of days of poor mental health than non-Hispanic Whites, whereas non-Hispanic Blacks with asthma reported significantly fewer days of poor mental health than non-Hispanic Whites. However, among individuals in the $25,000 to $34,999 income bracket, Hispanics with asthma reported fewer days of poor mental health than non-Hispanic Whites with asthma, although no differences in mental health emerged between non-Hispanic Blacks and Whites with asthma (Table 4).
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Depressive Symptoms
There was a significant income*asthma interaction on the number of days of depressive symptoms. Among those with asthma, those within the two lowest yearly income brackets (i.e., <$15,000, $15,000–$24,999) reported a significantly greater number of days of depressive symptoms than those within the $50,000 income bracket. A race/ethnicity*income*asthma interaction on depressive symptoms did not emerge (Table 3).
Anxiety Symptoms
There was a marginally significant income*asthma interaction on the number of days of anxiety symptoms (p = .0539). Post hoc analysis revealed that individuals with asthma, those with a yearly income of $15,000 to $24,999 reported a significantly greater number of days of anxiety than those with a yearly income of $50,000. Race/ethnicity did not modify this income*asthma interaction (Table 3).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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A three-way interaction among race/ethnicity, income, and asthma emerged on the number of days of poor mental health. Results suggested that, among the most impoverished, Hispanics with asthma reported a greater number of days of poor mental health than non-Hispanic Whites. This finding is consistent with those of Ford et al. (19), who reported a race/ethnicity by asthma interaction on mental health in their analyses of the 2000 BRFSS. However, to our knowledge, the results of the present study are the first to suggest that this relationship may be further modified by income and strongest among the most impoverished. This intriguing finding may suggest that the poorest mental health outcomes among individuals with asthma emerge when poverty is paired with stressors that differentially affect Hispanics, such as language barriers, immigration/naturalization, and acculturation. Interestingly, a different pattern emerged for individuals at the $25,000 to $34,999 income level. At this income level, Hispanics with asthma reported fewer numbers of days of poor mental health than non-Hispanic Whites. Although a number of reasons for this relationship may exist, it is plausible that the core Latino cultural value of familisma may buffer poor mental health among those with asthma in this income range, specifically. This income range likely encompasses families that are "near poor" and struggling with unstable or "precarious" employment. Familisma, a cultural value marked by reliance on and obligation to the family and reference to the family unit for identity, may result in tangible and emotional support that is especially adaptive for individuals who have some, but not many, economic resources.
Race/ethnicity and income independently modified the relationship between history of chronic asthma and number of days of depressive symptoms. Similar to the findings discussed above, Hispanics with asthma reported a significantly greater number of days of depressive symptoms compared with non-Hispanic Whites with asthma. Furthermore, the relationship between history of chronic asthma and greater number of days of depressive symptoms (as well as anxiety symptoms) emerged for the most impoverished. Once again, these findings are supported by prior research (19,30–33). In particular, lower SES, as determined by reported income level, may predispose a person to factors that are associated with the development of new-onset asthma or aggravation of existing asthma, such as poor housing conditions, which may result in exposure to indoor allergens and poor indoor air quality (34); low wage occupations, which may predispose an individual to myriad of asthmagens and toxicants (35); and absence of medical insurance, which may influence access to adequate health care (36). Similarly, economic and neighborhood deprivation are associated with poorer mental health and greater depression (34,37).
This study has several limitations. The study utilized a cross-sectional design; as a result, cause-and-effect as well as the temporal association among variables cannot be established. Another limitation of this study is that all data were collected via self-report; therefore, a medically documented history of asthma could not be obtained. In addition, all data were collected via telephone interview and subject to the validity concerns inherent to this interview format. Furthermore, the BRFSS study did not use validated psychological measures of mental health, and as such, it is unknown how well responses on the BFSS mental health items approximate clinically significant mental health impairment. Additionally, results based on the Healthy Days (Symptoms) Optional Module must be interpreted with caution, as only four states administered this module. Of these four states, only New York has a proportion of Hispanics/Latinos (16.1%) similar to that of the United States as a whole (14.4%). Thus, conclusions based on the Optional Healthy Days (Symptoms) Module may not be generalizable to individuals in areas with denser populations of Hispanic/Latinos, such as Arizona, California, Florida, and New Mexico (38). The external validity of these data may also limited by the fact that individuals who volunteered to participate in the Healthy Days (Symptoms) Optional Module may be different in important but unknown ways from those who declined to respond to these questions.
Future research should attempt to replicate the findings of the current study using a prospective cohort design, which will help establish the temporal association among the variables of interest. This research would benefit from the use of widely used and validated mental health measures, such as the Center for Epidemiologic Studies—Depression Scale (39) to assess depressive symptomatology and the State-Trait Anxiety Inventory (40) to assess anxious symptomatology. Furthermore, these findings suggest that future research target low socioeconomic status individuals with asthma for psychological and behavioral interventions, regardless of race/ethnicity. Although it is clear that these interventions must reach all vulnerable groups, it is possible that non-Hispanic Whites with asthma may be particularly vulnerable to the negative impact of poverty on mental health outcomes. Future research should examine the etiology of this vulnerability and design/implement individual, community, and/or public health interventions that may reduce this risk.
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NOTES |
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DOI:10.1097/PSY.0b013e31815ff3ad
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This article has been cited by other articles:
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  T. H. Chun, S. H. Weitzen, and G. K. Fritz The Asthma/Mental Health Nexus in a Population-Based Sample of the United States Chest, December 1, 2008; 134(6): 1176 - 1182. [Abstract] [Full Text] [PDF]
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