A holistic model for understanding and predicting depressive symptoms in african-american women

Journal of Communily Psychology Volume 19. Oclober 1991

A Holistic Model for Understanding and Predicting Depressive Symptoms in African-American Women

Jerome Taylor Delores Henderson

Department of Black Community Education Research and Development

Faculty of Arts and Sciences University of Pittsburgh

Beryl B. Jackson Department of Psychiatric Mental Health Nursing

School of Nursing University of Pittsburgh

A holistic model for understanding and predicting depressive symptoms in a sample of 289 African-American women was evaluated. Using a structural equation methodology, life events, social support, physical health problems, and internalized racialism were significant predictors of depressive symptoms. Although neither marital status nor religious orientation had predicted inverse effects on depressive symptoms, we found that the effects of socioeconomic status and developmental status on depressive symptoms were mediated through these and other variables specified in the model.

Survey and clinical studies indicate that women are more vulnerable to depression than men (Baskin, Bluestone, & Nelson, 1981; Gordon & Ledray, 1985). Among women, Blacks are more vulnerable than Whites (Eaton & Kessler, 1981; Frerichs, Aneshensel, & Clark, 1981). Given the higher risk of depression for Black women, the aim of this investigation is to evaluate the extent to which a holistic model of mental health problems is applicable to the specific problem of depressive symptoms in this population.

Taylor and Jackson's (1990a, 1990b) holistic model for understanding and predicting general mental health problems in African-American women features two background variables (developmental status and socioeconomic status), one physical status variable (physical health problems), one family structure variable (marital status), two ideological variables (religious orientation and internalized racialism), one social variable (social support), and one stress variable (life events). This model, which has been useful in ex- plaining and predicting alcohol consumption in African-American women (Taylor & Jackson, 1990a, 1990b), is structured around eight hypotheses.

1. Social support has an inverse effect on mental health problems (Beach, Arias, & O'Leary, 1986; Sarason, Sarason, & Shearlin, 1986; Turner & Noh, 1988; Veiel, 1987).

2. Life events have direct effects on mental health problems (Bargh & Tota, 1988; Langner & Michael, 1%3), and physical health problems (Bargh & Tota, 1988; Dohren- wend & Dohrenwend, 1974; Lennon, 1982; Rahe & Lind, 1971).

This study was made possible by award #lROlAGO5579-OlAl made to the Institute for the Black Family, University of Pittsburgh, by the Behavioral and Social Research Division, National Institute on Aging. Gratefully acknowledged is the assistance of Xiaoyan Zhang and consultation of Rollo Turner in the development of this paper. Requests for reprints should be sent to Jerome Taylor, Department of Black Community Educa- tion Research and Development, 3S09 Forbes Quad, University of Pittsburgh, Pittsburgh, PA 15260.

306

DEPRESSIVE SYMPTOMS IN BLACK WOMEN 307

3. Religious orientation-belief in the immanence of God in the world and in one's life- has an inverse effect on depression and life events (Hill, 1971; Idler, 1987; McNeil, Stone, & Kozman, 1985; Srole, Langner, Michael, Opler, & Rennie, 1962; Willets & Crider, 1988) and an indirect effect on social support (Idler, 1987; Taylor, 1986; Taylor & Chatters, 1986) and internalized racialism (Franklin, 1987; Karenga, 1980; Pierce, 1972; Taylor & Jackson, 1990b). The prediction that religious orientation will have a direct effect on internalized racialism, suggesting that as religious orientation increases Black internalization of Whites' stereotypes about Blacks increases, is consistent with the result of two recently completed studies using Black samples (Franklin, 1987; Taylor & Jackson, 1990b).

Internalized racialism- the extent to which Blacks identify with White racist conceptions of Blacks- has a direct effect on mental health symptoms and life events (Dressler, 1987; Taylor & Grundy, in press) and an inverse effect on social support (Brown, 1979; Denton, 1985; Gary & Berry, 1985; Taylor & Grundy, in press). As such, internalized racialism may be considered a negative form of Black cultural identity.

5 . Marital status has an inverse effect on depression, i.e., marrieds have fewer psychological problems than singles (Cargan, 1981 ; Dressler, 1983; Franklin, 1987).

6. Although we hypothesize that physical health problems have a direct effect on depression, we noted that some investigations of disabled and nondisabled persons have failed to find a difference.

7. Developmental status - chronological age, an index of biological maturity, and climacteric phase, an index of menopausal process - has direct effects on physical health problems (Cristifalo, 1988; Croake, Myers, & Singh, 1988) and religious orientation (Gibson, 1982; Watson, Howard, Hood, & Morris, 1988; Willits & Crider, 1988) and an inverse effect on life events (Chiriboga & Cutler, 1980; Dekker & Webb, 1974; Folkman, Lazarus, Pimley, & Novacek, 1987).

Socioeconomic status has a direct effect on marital status (Norton & Glick, 1976) and inverse effects on physical health problems (Kannel, 1981; Nance, 1984; Thompson, 1980; Weigley, 1984; Zambrana, 1987). religious orientation (Demerath, 1965; Dhruvarajan, 1988; Goode, 1966; Levin & Markides, 1986), and internal racialism (Caplan & Paige, 1968; Tomlinson, 1970).

A conceptual graph of expected relationships identified in propositions 1-8 is presented in Figure 1. In it, all variables identified in hypotheses 1 through 8 are represented along with the expected relationship between variables-" + " for direct, " - " for inverse. Thus the ''+" connecting DS with PHP affirms our expectation that developmental status is directly related to physical health symptoms; that is, as persons age they are likely to report a higher incidence of physical health problems. The "-" connecting DS with LE affirms our expectation that developmental status is inversely related to life events; that is, as persons age they tend to report a smaller number of life events. The remaining relationships in Figure 1 can be read in a similar manner. For three reasons, the conceptual model in Figure 1 was recast as a structural equation model. First, structural equation modeling is consistent with holistic thinking that evaluates relationships in context rather than in isolation. Second, structural equation methodology evaluates the relationship between variables disattenuated for unreliability, thus providing statistically error-free estimates of intervariable relationships. Third, structural equation methods provide a means of evaluating the comparative advantage of alternate models.

Figure 2 is the structural expression of the conceptual model in Figure 1. A one-to- one correspondence is evident between conceptual variables identified in Figure 1 and

4.

8.

308 TAYLOR, HENDERSON, AND JACKSON

FIGURE 1. General Model for Understanding Depression in African-American Women

DS = Developmental Status; PHP = Physical Health Problems; SES = Socioeconomic Status; MS = Marital Status; RO = Religious Orientation; IR = Internalized Racialism; LE = Life Events; SS = Social Support; DP = Depression.

their formal representation in Figure 2. Comparing Figure 2 with Figure 1, then, will prove useful in understanding the relationship between conceptual and structural representations of models A and B which are evaluated in this research.

Model A consists of two exogenous (“independent”) variables - €1 (developmental status) and [Z (socioeconomic status) and seven endogenous (“dependent”) variables - 71 (physical health problems), 72 (marital status), 73 (religious orientation), 74 (internalized racialism), 75 (life events), 76 (social support), and 117 (depression). In turn, exogenous variable €1 is defined by two indicators (XI, chronological age; X2, climacteric phase), and b by two indicators (X3, education; X4, income). Exogenous variable 71 is defined by two indicators (Y1, physical health symptoms at the moment; Y2, number of physician visits within the last 6 months), 72 by one indicator (Y3, 0 for single and 1 for nonsingle including cohabiting), 73 by two indicators (YJ, intrinsic religiosity; Y5, religious beliefs), 74 by two indicators (Y6, racist stereotypes; Y7, social stereotypes),


I I

d'

FIGURE 2. Structural Equation Model for the Understanding and Prediction of Depression in African-American Women

= Developmental Status, .5 = Socioeconomic Status, 91 = Physical Health Problems, 72 = Marital Status, 73 = Religious Orientation, 94 = Internalized Racialism, 75 = Life Events, 96 = Social Support. 9 7 = Depression.

7s by two indicators (Ys, stressors within the home; Y9, stressors outside the home), 76 by two indicators (Y 10, relatives; Y 1 1 , friends), 1 7 by one indicator (depressive symptoms). Measurement error is associated with 61 for exogenous and €1 for endogenous variables, and unaccounted for variance in endogenous equations is represented by ti. Finally, the effect of exogenous variables on endogenous variables is represented by Xij

and the effect of endogenous variables on endogenous variables by pij.

Alternate Model B, which posits an inverse effect of socioeconomic status on depressive symptoms, is identical to Model B with one exception: A direct line is drawn in Figure 2 from €2 to v7. Model B, then, evaluates the hypothesis that effects of socioeconomic status on depressive symptoms are direct and mediated, and Model A evaluates the hypothesis that effects of socioeconomic status on depressive symptoms are mediated only. If Model A is as efficient as or more efficient than Model B, then the case could be made that effects of socioeconomic status on depressive symptoms are mediated through variables specified in the model - physical health problems, marital status, religious orientation, and internal racialism. If Model B is more efficient than Model A, then the case could be made that socioeconomic status has effects on depressive symptoms over and beyond those accounted for by intervening variables. Comparison of models A and B, then, will help clarify how socioeconomic status, a key variable


in empirical research and policy analysis, influences depressive symptoms in this sample of African-American women.

Methods

Participants Participants were drawn from the first wave of an ongoing study of 599 African-

American inner-city women between 25 and 75 years of age. Because the overwhelming number of Black residents of this large Eastern city live in 27 residentially segregated inner-city neighborhoods (80.2% according to 1980 census information), the population universe for this study was defined on these neighborhoods. Of these 27 neighborhoods, 9 were randomly selected. The median percent Black in these neighborhoods was 86, with the range falling between 53 and 99. Two of these neighborhoods were strictly low income, the remaining seven varying in income level from low to upper- middle income. These neighborhoods contained three senior-citizen high-rise apartment buildings which also were included in our sample. We anticipated, then, that the results of this study would be roughly generalizable to this city and to other urban centers with similar demography.

The proportional sampling procedure used to obtain the parent sample of 599 has been described previously (Taylor & Jackson, 199Ob). Because of the sensitivity of structural equation modeling to artificial variance reduction associated with data attrition, we decided to use only those protocols that were complete in every respect. Application of this standard reduced sample size to 289. Demographically, mean ages of the parent and study samples were 43 (SD 15.80) and 40.83, respectively. About 32.0% and 35.0% of the parent and study samples were married or cohabiting. Educationally, mean educational attainment for the parent sample was 12.44, and for the study sample, 12.57. Mean income for the parent sample was $7,070 and for the study sample, $7,250. There were no significant differences between the parent and study samples on these demo- graphics. Overall, then, participants tended to be middle-aged women who primarily are unmarried, unemployed, undereducated, and relatively poor.

Instruments Depressive symptoms ( ~ 7 ) . The 13-item self-report depression scale of the Hopkins

Symptom Check List 90 (HSCL-90) was used. Each item was rated on a 5-point degree of distress scale: “not at all” (0) to “extremely” (4). Extensive studies of the reliability, validity, and factor structure of the HSCL-90 have been reviewed by Derogatis (1977) and Derogatis, Lipman, Rickels, Uhlenhuth, and Covi (1974). The internal reliability of the depression subscale was reported as .90 and test-retest as .82. Derogatis (1977) summarizes studies on validation of the depression scale across several inpatient, out- patient, and normal populations. On all test comparisons of validation the study reflected a high degree of convergent validity with other measures estimating the depression construct.

Social support (76). The Social Resources Inventory developed by Jackson (1982) was designed to measure quality and quantity of relationships with intimates, relatives (YIo), and friends (YII). Because many of the women in this study were without intimates, this component of the measure is not included in the analyses reported here. Of the remaining subscales, a reliability of .85 has been reported for Relatives, which consists of 11 items, and for Friends, which consists of 13. The validity of this scale has been reported by Jackson (1982).

DEPRESSIVE SYMPTOMS IN BLACK WOMEN 31 1

Life events (95). We adapted Tausig’s (1 982) comprehensive life events measure, which draws upon previous work by Rahe (1975), Holmes and Rahe (1967), and Dohren- wend and Dohrenwend (1978). We grouped items measuring stress events in areas of home, love and marriage, family, finances, health, and personal into a single indicator labeled “internal” (Ys) and stress events in the areas of work, legal, school, and other into a second indicator labeled “external” (Ys). These types correspond roughly to the point of origin of stressful events, inside or outside the family. We eliminated 13 items that were directly related to health- serious physical illness, mental illness, and so on-in order to avoid tautological overlap with other constructs in the model. To accommodate the unique racial and cultural experiences of African Americans, we added 5 items to the work component (e.g., “racial slur or insult”), 8 items to the finances component (e.g., “ran out of food money”), and 7 items to the other component (e.g., “murder in neighborhood”). With the loss of 14 and gain of 20 items, the modified inventory of stress events contains 124 items, 53 of which are Internal and 71 External.

Religious orientation ( ~ 3 ) . We used 9 items from Spilka, Kojetin, and McIntosh’s (1985) intrinsic religiosity scale (Y4) and 10 items from King and Hunt’s (1973) religious belief scale (Ys) to form twin indicators of religious orientation. From the King and Hunt scale we used such items as “I pray several times a day” and “My religious beliefs are what really lie behind my whole approach to life,” each rated true or false. From the Spilka scale we used such items as “I try hard to carry my religion over into all my other dealings in life” and “Quite often I have been keenly aware of the presence of God,” each rated on a 1-6 scale. The validity of both item sets has been reviewed in the primary references cited.

Internalized racialism (74). The extent to which respondents have internalized White stereotypes about Blacks is estimated from the Taylor, Dobbins, and Wilson (1972) Nadanolitization Scale. The 21-item racist component (Ya) measures the extent to which Blacks believe genetic or constitutional reasons account for apparent differences between Blacks and Whites (e.g., “Whites are better at reasoning than Blacks”) and a 9-item version of the social component (Y7) examines the extent to which Blacks feel generally uncomfortable around other Blacks (e.g., “Working for a Black person would create inner tension”). All items are rated on a 0-8 scale. Reliabilities for these two indicators of internalized racialism have been in the .80s. In samples of African Americans, internalized racialism has been found to be directly related to alcohol consumption (Jackson & Taylor, 1990b) and inversely related to marital satisfaction (Taylor, 1990; Taylor & Zhang, in press). Other validation studies using this measure are summarized in Taylor and Grundy (in press).

Marital status (92). Respondents reporting they were never married, separated, divorced, or widowed were coded 0, and those reporting they were married or living together were coded 1 (Y3).

Health background (al). Two indicators were used to estimate health background. The first indicator (YI), adapted from Moos, Cronkite, Billings, and Finney (198% is a checklist of 14 medical conditions ranging from anemia to cancer. For our predomin- antly Black population, we added four items: sickle cell disease, sickle cell trait, heart murmur or click, and brittle bones. Respondents indicated whether they were affected by the condition by checking “yes” or “no,” the sum of “yes” responses constituting the medical conditions indicator. The second indicator (Y2) was defined on the number of reported physician visits within the last 6 months.

3 12 TAYLOR, HENDERSON, AND JACKSON

Developmental status ([I). This latent variable was defined in terms of chronological age (XI) calculated from birthdates and climacteric status (X2) operationalized by procedures recommended by Lennon (1982). Based upon respondent responses to questions about the regularity of their menstrual cycle, those checking “comes regularly” were coded 1, those checking “more irregular than ever” or “stopped entirely” for 4 to 11 months were coded 2, those checking “stopped entirely for 1-2 years” were coded 3, those checking “stopped entirely for 3-4 years” were coded 4, and those checking “stopped entirely for 5 years or more” were coded 5 .

Socioeconomic status (&). This latent variable was estimated by two indicators, education (X3) and income (%), using forms developed by Jackson (1982).

Procedures Interviews were conducted in homes by carefully screened African-American proc-

tors between 22 and 55 years of age. They were recruited through local Black churches and the Black print and electronic media. Each of 20 proctors was given a list of ran- domized addresses for neighborhoods to which they were randomly assigned. All proctors had cars and were available to interview during days and evenings as well as on weekends over the 3-week period of data collection. Proctors were trained and prac- ticed in procedures for introducing themselves and the nature of the research to women on their lists. They received specific training in how to administer the consent form and each individual questionnaire in the battery along with tips on answering respondent questions. After the nature of the research had been explained, terms of remuneration presented ($20.00 cash), and the consent form signed, the proctor then introduced the booklet of questionnaires, which required 90 to 120 minutes to complete. While the respondent worked on a given inventory, the proctor retired a few feet away from the work area, checking periodically to see if the respondent had any questions. When each inventory was completed, the proctor then introduced the next until the last measure was completed. At this time proctors encouraged participants to share their perceptions of the experience. Before leaving, the proctor gave each respondent $20.00 in cash for participating.

Results The LISREL VI program developed by Joreskog and Sorbom (1984) was used to

evaluate basic and alternate models proposed in this research. In the first section we summarize adjustments required on the measurement side of all models, and in the second section we evaluate the adequacy of basic and alternate models.

Measurement Issues On the measurement side we assumed a priori that marital status could be estimated

with perfect reliability (1 .O) and that depressive symptoms could be estimated with moderately high reliability ( .85) , which was set based upon the .86 Cronbach alpha ac- tually obtained for participants used in this study. For remaining constructs, we set one A1 of each latent variable to a value of 1.0. This rescaling strategy, which produces estimates of Xis in relation to Xi, does not affect tests of hypotheses (Joreskog & Sorbom, 1978). Based upon preliminary application of LISREL VI, two a posteriori adjustments were made. First, it was necessary to constrain error terms on relative (Y 10) and friend (Y I 1 ) components of social support to equality. Without this adjustment, estimates could not be made for all parameters because the matrix containing these error terms was not positive definite. Second, we freed the education indicator to load on developmental


status as well as socioeconomic status. The negative modification index indicated that lower educational attainment was associated significantly with older age cohorts. Al- though this loading pattern was unexpected, it at least seemed reasonable for this urban sample of Black women. All models were evaluated in relation to a priori and posteriori adjustments identified. Table 1 gives the basic correlation matrix used as input for LISREL VI, along with variable means and standard deviations.

Overall, the coefficient of determination for observed variables, a generalized measure of reliability of the entire measurement model, was high, .99.

Structural Evaluation The graph of measurement and structural parameters associated with Basic Model

A are given in Figure 3. Basic Model A, which accounted for 27% of the variance in depressive symptoms,

was associated with a chi square of 147.31, df = 87, p < .01. Although chi square was associated with p < .01, several theorists suggest that ratio x2/df is a more sensi- tive index of fit for complex models of the dimension used in this study than p-level associated with chi square. In particular, a x2/df ratio in the range of 2.0-5.0 is usually regarded as a reasonable, although not a fail-safe (Kaplan, 1988) indicator of model

FIGURE 3. African-American Women

Structural Equation Model for the Understanding and Prediction of Depression in

[I = Developmental Status, €2 = Socioeconomic Status, 91 = Physical Health Problems, t / 2 = Marital Status, 1)) = Religious Orientation, qq = Internalized Racialism, 95 = Life Events, 96= Social Support, 97 = Depression.

W

L-

P

Tab

le 1

In

dica

tor

Mea

ns, S

tand

ard

Dev

iatio

ns,

and

Inte

rcor

rela

tions

for

Bas

ic M

odel

A

Var

iabl

e YI

Y2

Y3

Y4

Y5

Y6

Y7

Y8

Y9

YIO

Y11

Y12

XI

x2

x3

x4

Y1

Y2

Y3

Y4

Y5

Y6

Y7

Y8

Y9

YIO

Y11

Y 12

XI

x2

x3

x4

1.O

oo

0.225

1.OOO

0.026

-0.063

0.226

0.158

0.234

0.105

0.113

0.008

0.156

-0.00s

0.068

0.048

0.194

-0.068

0.115

0.073

0.040

0.170

0.110

0.098

0.362

0.151

0.316

0.202

-0.108 -0.010

- 0.053 - 0.058

1 .Oo

o - 0.038

- 0.033

- 0.083

- 0.044

- 0.003

0.149

0.008

0.005

-0.041

- 0.098

- 0.054

0.193

0.250

1 .O

oo

0.578

0.030

0.087

- 0.038

- 0.029

0.132

0.038

0.033

0.350

0.281

- 0.076

0.065

1 .O

oo

0.098

0.156

-0.106

- 0.068

0.129

0. I84

-0.120

0.476

0.387

- 0.035

- 0.019

I .Ooo

0.722

-0.119

0.057

0.030

0.120

0.082

0. loo

0.097

-0.295

- 0.269

1 .OOO

- 0.177

- 0.005

0.036

0.125

0.024

0.175

0.079

- 0.248

-0.150

1 .OOo

0.457

- 0.098

-0.198

0.278

- 0.373

- 0.264

0.184

0.075

1 .Ooo

-0.049

1.Ooo

-0.1 I6

0.473

l.Ooo

0.222

-0.207 -0.216

l.Oo0

-0.280

0.204

0.162

-0.121

-0.270

0.235

0.214

-0.060

-0.040 -0.085

0.075

-0.103

-0.019 -0.043 -0.011

-0.018

I .ooo

0.802

1.Ooo

-0.180 -0.121

1.OOo

-0.039 -0.040

0.384

1.oo

O

~ ~

~ ~~

M

1.475

2.212

0.359

18.927

6.888

41.985

19.556

5.521

2.714

40.479

76.869

8.231

41.317

1.131

3.568

7.309

SD

2.434

2.149

0.481

4.935

2.792

34.354

10.8

44

4.717

2.7%

12.713

22.291

8.130

14.492

1.366

1.718

5.293


acceptability. That- x2/df for Basic Model A is 1.66 suggests that it is reasonably consistent with hypotheses implied by it, an inference consistent with a goodness of fit index (GFI) of .94 and root and mean square residual (RMS) of .06. For Basic Model A, hypotheses 1,2, 3,4,5, 7, and 8 were partially to completely corroborated. Unexpected, however, was the direct effect of religious orientation on life events. Since the zero-order disattenuated correlation between religious orientation and life events was in the predicted direction ( - .14), the most likely explanation for this unexpected finding is that developmental status, which had opposite effects on religious orientation (.60) and life events ( - .47), spuriously mediated the direct effect of religious orientation on life events (.14). This implication is consistent with a previous application of the model (Taylor & Jackson, 1990b).

Alternate Model B, which also accounted for 27% of the variance in depressive symptoms, was associated with a chi square of 146.93, df = 86, p < .05. Because differences in chi square are distributed as chi square, it was possible to evaluate the relative fit of basic and alternate models. From the difference in chi square for basic and alternate models, 0.38 with 1 df, we conclude that addition of the direct effect of socioeconomic status on depressive symptoms failed to net an explanatory gain over the basic model.

Discussion Model

Formal evaluation of basic and alternative models indicated that effects of socioeconomic status on depressive symptoms are primarily mediated through variables stipulated in the model - physical health problems, marital status, religious orientation, and internalized racialism. This finding, consistent with application of our holistic model to the prediction of alcohol consumption (Taylor & Jackson, 19OOb), provides a proc- essual view of how structural variables influence symptom expression in African- American women. Indeed, an advantage of the holistic model is that it helps generally to clarify theoretical relationships among variables that often are examined in isolation.

Life events were directly related to depressive symptoms and physical health problems as predicted (Hypothesis 1) . Because physical health problems were also directly related to depressive symptoms (Hypothesis 5) , the total effect of life events on depressive symptoms is both direct and mediated. The basic model, then, helped to clarify complex pathways over which stress affects the reporting of depressive symptoms.

Social support had the predicted inverse effect on depressive symptoms (Hypothesis 2) which was not, however, as sizable as the total effect of life events on depressive symptoms. In the present sample, then, it appears that the density or cadence of stressful events may have a greater magnitude of effect on depressive symptoms than the perceived availability and involvement of relatives and friends.

For Hypothesis 3 the predicted direct effect of religious orientation on internalized racialism and inverse effect of religious orientation on social support were supported. The predicted inverse effects of religious orientation on life events and depressive symptoms were not corroborated. Although total effect of religious orientation on depressive symptoms was miniscule, we noticed that religious orientation for this sample had oppo- sitely directed effects on depressive symptoms. On one hand, religious orientation had an inverse effect on depressive symptoms through its direct effect on social support. On the other hand, religious orientation had a direct effect on depressive symptoms through its direct effect on life events and internalized racialism. That the unexpectedly direct effect of religious orientation on life events was spuriously mediated by developmental


status removes the interpretive dilemma of accounting for the direct effect of religious orientation on depressive symptoms through life events. What remains, however, is the interpretive problem embodied in Hypothesis 3 that predicted a direct effect of religious orientation on internalized racialism (which in turn is directly related to depressive symptoms). Contrary to expectations associated with Black liberation theology (Stallings, 1988), women in this sample who reported higher levels of religious orientation also tended to identify with White racialist stereotypes about Blacks. Religious orientation, then, had culturally oppressive rather than liberating effects on women in this study. To the degree this pattern is replicated (cf. Taylor & Jackson, 1990b), there may be a need to reexamine ideology and praxis of theological traditions within the contem- porary Black church.

Only that portion of Hypothesis 4 predicting a direct effect of internalized racialism on depressive symptoms was corroborated. That cultural identity, net the effects of life events, social support, religious orientation, marital status, and physical health problems, should have significant impact on depressive symptoms suggests the relative importance of this underinvestigated variable. This implication is consistent with results of other studies which indicate that internalized racialism is inversely related to marital satisfaction (Taylor, 1990) and directly related to alcohol consumption (Taylor & Jackson, 1990b). Negative (and positive) cultural identity among African Americans may play an unsuspectedly important role in health and social issues of a wide range.

With the exception of marital status (Hypothesis 5 ) , all hypotheses involving background variables were supported - socioeconomic status (Hypothesis 7) and developmental status (Hypothesis 8). Although factors mediating effects of socioeconomic status on depressive symptoms have been discussed, we have not discussed factors mediating effects of developmental status on depressive symptoms. Our results indicated that iiging, as estimated from our developmental status construct, simultaneously has direct and inverse effects on depressive symptoms. Through two pathways - DS-LE-Dep; DS-LE- PHP-Dep - aging had inverse effects on depressive symptoms, and through two pathways - DS-RO-LE-Dep; DS-RO-IR-Dep - aging had direct effects on depressive symptoms. Together, these results indicate the complexity of aging effects, which were neither uniform nor unidimensional.

Implications Results associated with Models A and B have theoretical and intervention implica-

tions that we consider briefly.

Theory From the viewpoint of theory, application of our holistic model to diverse health

outcomes may serve to identify communalities and uniquenesses of processes mediating these outcomes. For example, social support was inversely related to depressive symptoms in this study but unrelated to alcohol consumption in a prior study (Taylor & Jackson, 1990b), leading us to speculate that specific normative support for alcohol consumption may be more predictive than general socioemotional support of relatives or friends. We further speculated that normative support may be more critical for addic- tive behaviors, whereas socioemotional support may be more critical for neurotic symptoms. As a second example, we found that physical health problems were directly related to depressive symptoms in the present study but were inversely related to alcohol consumption in a previous study (Taylor & Jackson, 1990b). Physical illness, then, seemed to have opposite effects on alcohol consumption and depressive symptoms. In other


respects, however, application of our model to understanding and predicting depressive symptoms and alcohol consumption was structurally similar. We anticipate that future applications of our model may help to identify similarities and differences in how mental and physical health outcomes are mediated. These profiles of similarities and differences could advance our understanding of illness processes and provide clues on how to reduce the risk of illness in populations at risk.

Intervention Results of this study have potential implications for microsystemic, mesosystemic,

and macrosystemic interventions, which, we argue from the perspective of holistic theory, are directly or indirectly related to the mental health of African-American women.

At the microsystemic level, prominent effects of life events, social support, and physical health problems on depressive symptoms suggest the need for programs to enhance coping skills, to improve social management skills, and to encourage health promotion. Enhancement of coping skills may be especially important because Black women tend to experience appreciably higher levels of stress than White women. Therefore interventions to assist clients in the adaptive appraisal and management of life events and daily hassles may have beneficial impact upon African-American women living in conditions of socioeconomic risk. Strategies for making and maintaining friendships - specific communication skills such as active listening and nondefensive responding - could enhance the quality of social support. Health promotion programs that consist of appropriate diet, exercise, and preventive care specifically targeted to African-American women may have direct and mediated positive effects on mental health. As a set, interventions to enhance coping skills, social management skills, and healthy life-styles may be of critical importance because life events, social support, and physical health explained significant portions of the variance in depressive symptoms.

At the mesosystemic level, the roles of religious orientation, internalized racialism, and socioeconomic status in depressive symptoms suggest the need for theological agenda that enhance spiritual development in ways that are fully liberating, for cultural programs that replace negative stereotypes with positive attitudes about Blacks, and for social programs that improve the educational and economic standing of Blacks. These considerations have implications for church programs that enhance the level of cultural appreciation, for preaching that challenges stereotypic conceptions of Blacks, and for teaching that celebrates the talents of Black inventors, scientists, artists, humanitarians, and leaders. Community organizations including YMCA, YWCA, and Urban League could offer motivational seminars and job-training opportunities to improve the socioeconomic level which was found in this study to be indirectly linked to the mental health of inner-city African-American women.

At the macrosystemic level, public and cultural policies supportive of identified microsystemic and mesosystemic interventions should be promoted. Public policies that support job development, technical training, and full employment may have indirect effects on the mental health of Black women. Cultural policies promoted by church ad- judicatories that emphasize liberatory preaching, teaching, and programming may have direct and indirect effects on Black health. Cultural policies-promoted by national Black organizations or by White organizations serving the Black community - that emphasize Black cultural training may have salutary effects on Black health.

In general, we conclude that enhancing the quality of mental health of African- American women in particular and perhaps African Americans in general may require more of an ecosystemic perspective than a strictly clinical approach.


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A holistic model for understanding and predicting depressive symptoms in african-american women