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This study uses a national probability sample of older adults to examine racial and ethnic differences in the use of professional services and informal support for a stressful personal problem. Using data from the National Survey of American Life, this study focuses on African Americans, Black Caribbean immigrants, and Whites aged 55 years and older who experienced a personal problem that caused them significant distress (n=862). Multinomial logistic regression is used to estimate the association of race with the use of professional services only, informal support only, both professional services and informal support, or no help at all, while controlling for demographic and socioeconomic variables, characteristics of the informal support network, the type of problem experienced, and experiences of racial discrimination. Examining the use of professional services and informal support provides a more complete picture of racial and ethnic differences of help-seeking behaviors among older adults, and the factors associated with the sources from which these adults request help. Most respondents use informal support alone or in combination with professional services. Black Caribbeans are more likely than African Americans to rely on informal support only, whereas African Americans are more likely than Whites to not receive help. However, these findings are accounted for by differences in social support and experiences of discrimination.
Professional services and informal support are both important in providing care to older adults. Informal helpers are more likely to address tasks that require little skill, noncritical situations, and events that occur at unpredictable times whereas professional support is more appropriate for tasks requiring specialized skills and resources (Litwak, 1985). Further, professional services and informal support networks can function in a complementary manner to help individuals cope with problems. For instance, to manage chronic health problems such as diabetes or hypertension, older adults need adequate medical care and supervision from professionals. In combination with this professional support, informal helpers can reinforce healthy behaviors and coordinate care. Ideally, professional services and informal support should work together to address changing situations of older adults, such as when changes occur in the nature of the problem, the level of care needed, and the level of stress or demands placed on informal helpers (Edelman & Hughes, 1990; Litwak, 1985). Despite the importance of this issue, little research has explored the demographic and social network factors influencing the use of professional and informal support among older adults, particularly within distinct race and ethnic groups. This study examines these correlates using a national probability sample of older African Americans, non-Hispanic Whites, and Black Caribbeans.
Several theoretical models have been developed to help explain help-seeking behavior. The most widely recognized, the Andersen model (Andersen & Newman, 1973), argues that help-seeking behaviors can be explained by a combination of factors, including predisposing (e.g., demographic variables including age, education, social class), enabling (e.g., income, community services) and need (an individual’s perceived need for care) factors. One criticism of this and similar models is the model’s failure to account for social and psychological factors. In particular, Kasl (1974) argued that social support was critical in understanding help-seeking behavior. Members of a person’s support network are crucial for (a) helping an individual understand his or her need for help, (b) facilitating access to care, and (c) helping the individual adhere to the medical care regimen. Thus, social network members not only influence the use of professional services but also provide direct assistance themselves.
This paper uses Krause’s (1990) model of illness behavior in later life. Krause’s model builds upon the work of Andersen & Newman (1973) and Kasl (1974), and includes demographic factors, socioeconomic status, and social support. Most important for the current study, Krause expanded previous models by including informal support, self-care, and professional services as possible outcomes of illness behavior. Krause contended that examining multiple sources of care and the concurrent use of professional services, informal support, and self-care could provide a better understanding of illness behavior among older adults. Finally, Krause’s illness behavior model incorporated the influence of stress, giving particular attention to the way in which stressful life events might create or exacerbate health problems. Potential ways of coping with stress and subsequent problems include seeking professional help, turning to social networks, engaging in self-care, or some combination of these actions. The Krause model is ideal for the present analysis that investigated help seeking from professional and informal sources to secure assistance for a range of problems, including physical illness.
Most recent research on the concurrent use of professional services and informal support among older adults has been conducted in countries with systems of care that differ substantially from the structure of the systems in the United States (e.g., Bolin, Lindgren, & Lundborg, 2007; Dale, Saevareid, Kirkevold, & Soderhamn, 2008; Ke, Montgomery, Stevenson, O’Neill, & Chakravarthy, 2007; Larsson & Silverstein, 2004; Litwin & Attias-Donfut, 2009; Nordberg, von Strauss, Kareholt, Johansson, & Wimo, 2005; Penning, 2002). This research has suggested that even across different contexts and methodological approaches (e.g., community samples, population surveys), informal support—whether alone or in combination with professional services—consistently played a more central role in the care of older adults than professional services (e.g., Blieszner, Roberto, & Singh, 2001; Cohen, Miller, & Weinrobe, 2001; Davey et al., 2005; Penning, 2002). Even when the older adult had extensive care needs, informal supports were most often the main source of help, whereas professional service providers supplemented care as needed (Cohen et al., 2001; Davey et al., 2005; Nordberg et al., 2005; Penning, 2002).
Those who provide informal supports are pivotal because they typically provide direct assistance in response to stressful life events (e.g., the death of a loved one) as well as help in coping with the emotional and physical reactions to these events (Krause, 1990). Moreover, when informal assistance alone is insufficient to address a problem, then informal helpers can facilitate access to professional services. Informal support networks, and the information and resources within the control of those networks, have an important bearing on whether professional help is sought as well as the circumstances associated with that help seeking, such as the timing and what sources are used for securing assistance (Pescosolido & Boyer, 1999).
Most research in this area has focused on long-term care; assistance with activities of daily living (ADLs); instrumental activities of daily living (IADLs); or help in response to chronic physical, mental, or cognitive problems and disabilities. In contrast to this literature, help seeking for stressful personal problems has been understudied. Although the present investigation draws on the literature on help seeking for health and medical issues, the distinction is important because help seeking in response to stressful personal problems is likely different than help seeking for medical issues. In sum, the present study focuses on a spectrum of stressful personal problems (e.g., emotional or interpersonal problems, the death of a loved one, economic problems) as well as medical and health issues as one class of personal problems that older adults are likely to identify as stressors.
Studies of racial and ethnic differences in help-seeking behavior show consistent racial and ethnic disparities in the use of professional services. These studies have reported mixed results regarding the use of professional services and informal support. In some cases, older African Americans have been found to rely more frequently on a combination of professional services and informal support than either younger African Americans or older Whites (Caldwell, Neighbors, & Jackson, 1996; Miner, 1995; Neighbors & Jackson, 1984). As compared with their White counterparts, vulnerable older African Americans were less likely to have help following a hospitalization even when informal support was available (Peng, Navaie-Waliser, & Feldman, 2003) and overall were less likely to receive assistance for functional limitations (Norgard & Rodgers, 1997), and more likely to rely on professional services than informal supports (Black et al., 1998). These findings suggested that older Black Americans in more compromised circumstances might have fewer support resources available overall, or have care needs that exceeded the capacities of the available informal helpers.
Further, research has suggested that experiences of racial discrimination can influence the help-seeking behaviors of members of racial/ethnic groups and their use of formal health and social services (Smedley, Stith, & Nelson, 2003). Researchers have shown an association between study participants’ experiences of racial discrimination with delays in seeking medical help and reduced compliance with treatment regimens (Casagrande, Gary, LaVeist, Gaskin, & Cooper, 2007). Although much less is known about how discrimination influences the use of other sources of care, some evidence supports the association of discrimination experiences with decreased use of both informal support and professional services (Spencer & Chen, 2004). This research has primarily focused on the effects of discrimination on help-seeking behaviors for medical care, and has given less attention to help-seeking behaviors related to stressful personal problems more broadly. The present investigation of perceived discrimination and help-seeking behaviors is part of the broader literature on discrimination and health (e.g., Kessler, Mickelson, & Williams, 1999; Krieger, 1999; Williams, Neighbors, & Jackson, 2008). Collectively, this research confirms that perceived discrimination (a) is prevalent in the population, especially among non-Whites; (b) has effects comparable with those of other major life stressors (Kessler et al., 1999); (c) is associated with a variety of negative self-perceptions (e.g., feelings of powerlessness, being worthless, helpless); and (d) is predictive of poor mental and physical health outcomes (e.g., psychological distress, anxiety, depression; Krieger, 1999; Mustillo et al., 2004; Williams et al., 2008). Discrimination and health associations are noted for both everyday and major lifetime discrimination events, involve diverse health behaviors and risk factors, occur in diverse samples of the population, and are found in both qualitative and survey studies using community, regional and national samples (for a review, see Williams et al., 2008).
Perceived discrimination can instill feelings of powerlessness and helplessness that undermine personal control and self-efficacy. Thus, perceived discrimination can inhibit coping efforts, including seeking help for problems (Krieger, 1999; Mustillo et al., 2004). Moreover, efforts to cope with the stress associated with discrimination have the potential to precipitate behaviors that delay treatment or substitute self-medication and informal assistance for formal help seeking (Krieger, 1999; Mustillo et al., 2004). Finally, perceived discrimination may constitute an additional stressor that exacerbates chronic stressors, increasing an existing significant stress burden, and inhibiting help-seeking actions (Williams et al., 2008).
Further, help-seeking behaviors and use of supports are negatively affected by the racial and ethnic discrimination that occurs within health and social service settings and institutions (Spencer & Chen, 2004). A focus group study of racial/ethnic health disparities (Grady & Edgard, 2003) found that participants not only related numerous experiences of negative provider attitudes and problematic interactions with service providers (e.g., prejudice, lack of respect, stereotyping), but also possessed a sophisticated awareness of the systemic character of segregation, discrimination, and institutional racism within health care systems. Circumstances and interactions such as these generate a lack of confidence and trust in formal systems of care (Smedley et al., 2003) that negatively influences the willingness of racial/ethnic minorities to seek formal assistance (Spencer & Chen, 2004).
Ethnic differences within the Black population further complicate efforts to understand help-seeking behaviors of older adults. Although Blacks in the United States are generally viewed as a homogenous group, this population segment is becoming increasingly diverse. The growing numbers of immigrants from the Caribbean region are routinely included in the category of Black race without reference to their ethnicity. Black Caribbean immigrants in the U.S. population number 1.5 million according to the 2000 U.S. Census, representing a significant percentage of the growth of U.S. Black population and a sizable component of the Black population in select urban centers (McKinnon, 2001). Nonetheless, we have limited information about the social and demographic characteristics of Black Caribbeans and no information about this population’s use of professional services and informal support.
Black Caribbeans have cultures, demographic profiles, national origins and histories, and languages and dialects that are distinct by country-of-origin within the Caribbean region and are distinct from those of African Americans born in the United States. Historically, Black immigration from the Caribbean region was a selective process in which high levels of literacy, education, and occupation (e.g., nursing) were specifically targeted. The immigration process itself selects for individuals who are generally healthier and have strong social networks and resources (Bashi, 2007). Further, when relocation is motivated by economic factors, immigrants are particularly motivated to exploit available labor market opportunities (e.g., accepting low-wage, low-status jobs). Employers’ beliefs regarding Black Caribbeans’ strong work ethic and drive are reflected in preferential hiring practices that advantage these immigrants relative to native African Americans and contribute to Black Caribbeans’ higher rates of labor force participation and higher levels of education and income (Logan, 2007; Waters, 1999).
As a consequence of their higher socioeconomic status, Black Caribbeans may be inclined to access professional services when faced with problems. Alternatively, because the immigration experience is often intensely focused on maintaining immigrant social networks and communities that preserve the country-of-origin culture (Bashi, 2007), Black Caribbeans may eschew formal supports in favor of informal assistance to address life problems. Further, despite their relatively advantageous socioeconomic profile, race and racism have a profound impact on the immigration experience of Black Caribbeans (Bashi, 2007; Waters, 1999). Numerous accounts (Foner, 2001; Vickerman, 1999, 2001) have described Black Caribbean immigrants’ emergent understanding of U.S. conceptualizations of race as a major stratifying dimension as well as their encounters with systems of racial privilege and discrimination that operate across diverse sectors of society. Accordingly, Black Caribbeans’ use of professional services may be influenced by these experiences of racial discrimination in ways that are similar to African Americans.
Although research on help seeking among Black Caribbeans is sparse, recent studies have provided preliminary information. This research has suggested that similar to African Americans, Black Caribbeans underutilize mental health services (Neighbors et al. 2007). Further, observed racial differences in informal support networks for Black Caribbeans and Whites do not always mirror the differences found in comparisons of African Americans with Whites (Neighbors et al., 2007; Taylor, Chatters, Woodward, & Jackson, 2007; Woodward et al., 2008). That is to say, available research has indicated that Black Caribbeans are both similar to and different from African Americans regarding help seeking and use of informal support. More research is needed to thoroughly understand how demographic, socioeconomic, social network variables and racial discrimination differentially affect help-seeking actions across these groups.
Researchers have also identified persistent racial and ethnic differences in health and mental health service use (Smedley et al., 2003). For example, only 32% of Black Americans with a mental disorder were found to use professional services (Neighbors et al., 2007) as compared with 41% of the overall population (Wang et al., 2005). In addition, racial minorities are less likely to receive mental health treatment (Wang et al., 2005) and receive lower rates of cardiovascular procedures as compared with Whites (Schneider et al., 2001). Untreated mental and physical illness can have long-term adverse health effects, including increased risk of mortality (e.g., Peterson, Shaw, DeLong, & Pryor, 1997; Sachs-Ericsson, Joiner, & Blazer, 2008; Unutzer et al., 1997). Although it is possible that those not using professional services are instead receiving help from informal support networks or engaging in self-care activities, further study is required to clarify the relationship of race and ethnicity to possible outcomes and to inform efforts to address disparities in service use.
The purpose of this study is to describe racial and ethnic differences in help seeking in a national probability sample of older adults. Specifically, this study addresses three research questions. First, what combination of professional services and informal supports do older adults use when faced with a serious personal problem? Second, how are race and ethnicity associated with help seeking for a personal problem? Third, what demographic, socioeconomic, and social support factors are associated with help seeking for a stressful personal problem?
This study builds on previous work to examine racial and ethnic differences in informal and professional help seeking for a stressful personal problem. The analysis focuses on differences both between and among three groups of older adults—African Americans, Black Caribbeans, and non-Hispanic Whites—who have experienced a stressful personal problem. Consistent with Krause’s model of illness behavior, we look beyond the use of professional services and informal supports alone to examine four possible help-seeking options: (a) using professional services only, (b) using informal support only, (c) using both professional services and informal support, and (d) using no form of help or support.
However, this study differs from Krause’s model of illness behavior in two important ways. First, this study considers race/ethnicity as a central component known to shape service use as well as the structure and use of informal networks. In addition, because the data include representative samples of Black Caribbeans as well as African Americans and non-Hispanic Whites, we considered within-group differences (i.e., ethnicity) among older Black Americans, as well as Black-White differences. This depth of the investigation is important because although between-group differences can confirm the existence of racial/ethnic disparities in help seeking, understanding within-group differences can shed light on the mechanisms contributing to those disparities. In addition, despite the growing number of immigrants from the Caribbean, we have little information about their use of professional and informal support resources. Notably, this study is the first examination of this issue among older Black Caribbeans.
Second, research has suggested that as compared with younger age groups, older adults are more vulnerable to the negative effects of stressful life events, and even at lower levels of exposure (Cairney & Krause, 2008). Further, Krause (1990) argued that stressful life events could exacerbate physical illness that, in turn, could lead to coping responses among older adults (e.g., initiating self-care or seeking help from informal or professional sources). Although Krause’s model considered only medical help-seeking behaviors, the present study has broadened the research in this area by focusing on older adults’ need for help beyond physical illness to include a range of stressful personal problems. This expanded perspective permits an exploration of how help-seeking action varies by type of problem, and the role of demographic, socioeconomic, and social factors in these processes.
This study used data from the National Survey of American Life: Coping with Stress in the 21st Century (NSAL), a national multistage probability design survey (Jackson et al., 2004). Face-to-face interviews were conducted from 2001 to 2003 by the Institute for Social Research Survey Research Center, in cooperation with the Program for Research on Black Americans. The overall response rate was 72.3% with response rates of 70.7% for African Americans, 77.7% for Black Caribbeans, and 69.7% for non-Hispanic Whites. The African American sample is the core sample of the NSAL and consists of 64 primary sampling units (PSUs). Fifty-six of these PSUs overlap substantially with existing primary areas of the Survey Research Center’s national sample. The remaining eight PSUs were chosen from the South to represent African Americans in the proportion in which the population is distributed nationally. Both the African American and White samples were selected exclusively from these targeted geographic segments in proportion to the African American population. Particularly important for this study, the NSAL includes the first major probability sample of Black Caribbeans ever conducted. Black Caribbeans are defined here as persons who trace their ethnic heritage to a Caribbean country, but who now reside in the United States, are racially classified as Black, and who are English speaking (but may also speak another language). The Black Caribbean sample was selected from two area probability sample frames: the core NSAL sample and housing units from geographic areas with a relatively high density of persons of Caribbean descent.
In both the African American and Black Caribbean samples, it was necessary for respondents to self-identify their race as Black. Those self-identifying as Black were included in the Black Caribbean sample if they answered affirmatively when asked if they were of West Indian or Caribbean descent, said they were from a country included on a list of Caribbean countries presented by the interviewers, or indicated that their parents or grandparents were born in a Caribbean country. Face-to-face interviews were conducted with 6,082 persons age 18 years or older, including 3,570 African Americans, 891 non-Hispanic Whites, and 1,621 Black Caribbeans. Roughly three-quarters (77.49%) of the NSAL respondents indicated that they had experienced a serious personal problem. Of these respondents, 862 were age 55 or older, and these older adults comprised the study’s analytic sample.
Krause’s (1990) illness behavior model serves as the conceptual framework for the study and focuses on both professional services and informal support as possible outcomes. Respondents were asked to describe the most serious personal problem they had experienced, which had also caused them a significant amount of distress. Respondents were asked if they had discussed this problem with family or friends (i.e., informal helpers). The respondents were also given a list of professional service providers and asked if they had discussed the identified problem with any of the professionals. Professional service providers included psychiatrists; other mental health professionals such as a psychologist, psychotherapist, social worker, mental health nurse or counselor; a family doctor; any other doctor or health professional; a religious or spiritual advisor such as a minister, priest, rabbi, or pastor; any other healer; a self-help or mutual support group; or any other professional. These responses were used to create a dependent variable with four mutually exclusive categories of help seeking: (a) professional services only, (b) informal support only, (c) both professional services and informal support, or (d) no outside help at all. However, participants were not asked specifically about self-care responses; therefore, responses indicating no use of informal or professional services may indicate either unmet need for care or that the individual engaged in self-care behaviors.
The main correlate of interest is race/ethnicity (African American, Black Caribbean, or non-Hispanic White). African American and White are both used as reference categories, which allows for comparison among Black Americans (Black Caribbean vs. African American) as well between Blacks and Whites (White vs. African American and White vs. Black Caribbean). Demographic variables include a continuous measure of age and gender. Socioeconomic status was measured by education (high school or less vs. more than high school) and a continuous measure of household income. Krause’s model controls for these demographic variables, and these variables are consistently associated with the use of both professional services and informal support.
The stressful life event that triggers a coping response is a key component in Krause’s model. For this study, we examined how help-seeking responses varied across types of stressful personal problems. Respondents were asked, “What is the most serious problem you have faced in your life?” and their answers were recorded verbatim. Based on the responses, the type of problems were coded into one of the following five categories: (a) physical (e.g., poor health, accident), (b) emotional (e.g., depression, unhappiness, self-doubt), (c) interpersonal (e.g., difficulties with close family and friends, divorce), (d) death of a loved one, or (e) an economic problem (e.g., poor or declining financial status, loss of assets). In multivariate analyses, the problem type was recoded as a dichotomous variable comparing those who experienced a physical problem against all other types of problems. In this way, we build on Krause’s model by comparing illness behavior (i.e., seeking help for a physical problem) to coping responses reported for other types of problems (nonphysical).
Five variables described the older adults’ networks of family and friends: (a) a continuous measure of the number of family helpers; (b) frequency of contact with family members and (c) frequency of contact with friends (both used a 6-point scale ranging from never/hardly ever [coded as 0] to nearly everyday (4 or more times a week) [coded as 5]); and (d) subjective family closeness and (e) subjective friend closeness (both used a 4-point scale ranging from not close at all [coded as 0] to very close [coded as 3]). Multiple network measures allowed us to assess the relationship of help-seeking actions with various aspects of social support and social networks (Cohen et al., 2000; Corrigan et al., 2003; Lincoln et al., 2003; Macdonald et al., 2004). Finally, two dichotomous variables related to race-related discrimination were used, with one indicating a major experience of race-related discrimination and the second indicating the respondent had experienced everyday race-related discrimination.
The first phase of analysis presents means and percentages of key correlates by race and ethnicity. The Rao-Scott chi-square statistic is used for categorical variables and an F means test for continuous variables. This step is followed by analysis using multinomial logistic regression to test the association of race/ethnicity with the use of professional services and informal support while controlling for the other variables. To maintain the most parsimonious model possible, a Wald test was run for each variable in the model. In this process, some variables that did not contribute significantly to the model at p<.10 (e.g., marital status, living arrangement) were removed (Harrell, 2001). The format and interpretation of this analysis is similar to dummy variable logistic regression and involves contrasts between a comparison and an excluded category. However, comparisons between selected categories and the excluded category involve both the dependent variable and selected independent variables (as opposed to only selected independent variables in standard logistic regression). Given the focus of this study, and the fact that multinomial logistic regression analysis provides redundant results, only three comparisons are presented: (a) professional services only versus both professional services and informal support, (b) informal support only versus both professional services and informal support, and (c) no help at all versus both professional services and informal support. Assumptions for multinomial logistic regression (i.e., low collinearity, independence of irrelevant alternatives, and mutually exclusive categories) were met.
We used a hierarchical approach to test the association of race/ethnicity with use of professional and informal helpers. The first model included only race/ethnicity as the main correlate of interest. The remaining correlates were entered in blocks, beginning with less mutable correlates, to determine which types of variables influenced the relationship between race/ethnicity and help seeking, controlling for variables added in previous blocks. Thus, Model 2 added age and gender, Model 3 added education and household income as measures of socioeconomic status, Model 4 added the type of problem, Model 5 added the social support/social network variables, and Models 6 and 7 added the measures of discrimination separately. All statistical analyses were performed using the survey commands in STATA 10.0 accounting for the complex multistage-clustered design of the NSAL sample, unequal probabilities of selection, nonresponse, and poststratification to calculate weighted, nationally representative population estimates and standard errors.
The analytic sample for this study included 862 adults aged 55 years and older who reported having experienced a personal problem that caused them significant distress. As shown in Table 1, most respondents used informal support for personal problems (84.15%) either alone (26.47%) or in combination with professional services (57.68%). Only 6.6% relied solely on professional services and 9.25% reported not receiving any help at all. Over half (52.9%) of the sample was African American, 19.37% was Black Caribbean, and 27.73% was non-Hispanic White. The average age was 66.38 years (SD=8.39). More than half of the sample was female (55.48%) and the majority (60.81%) had 12 years or less of formal education. The average household income was $39,686.17 (SD = $42,142.88). The most frequently reported problem was the death of a loved one (27.26%), followed by interpersonal problems (25.18%), and physical health problems (20.36%). Respondents reported an average of 7.41 (SD=8.67) of family helpers. On average, respondents have more frequent contact with family (M=4.10, SD=1.16) than with friends (M=3.75, SD=1.37), and are closer to family members (M=2.68, SD=.59) than to friends (M=2.39, SD=.72). Respondent self-reports indicated that 20% of the sample had experienced at least one incident of major race-related discrimination in their lifetime and 20% experienced everyday discrimination.
Significant bivariate comparisons indicated that a higher proportion of Whites (8.29%) used professional services only compared with African Americans (3.39%) and Black Caribbeans (2.44%). More Black Caribbeans (48.01%) used informal support alone compared with both African Americans (31.26%) and Whites (23.39%). A higher proportion of Whites (61.43%) used both professional services and informal support as compared with both African Americans and Black Caribbeans, whereas more African Americans used both help sources (51.23%) as compared with Black Caribbeans (39.71%). However, more African Americans reported not using any source of outside help (14.12%) as compared with Black Caribbeans (9.84%) and Whites (6.88%). In terms of type of problem, African Americans more frequently reported experiencing the death of a loved one (34.41%) or economic problems (13.95%) than Whites or Black Caribbeans. More Black Caribbeans reported emotional (28.40%) and physical (24.08%) problems, and a higher proportion of Whites (29.17%) reported interpersonal problems. Black Caribbeans reported significantly fewer family members on average (M=5.65, SD=8.58) available to provide help compared with Whites (M=7.75, SD=9.59) or African Americans (M=6.82, SD=8.14). In addition, Black Caribbeans reported less frequent contact with friends (M=3.28, SD=1.42) than both Whites (M=3.74, SD=1.33) and African Americans (M=3.82, SD=1.37). Finally, reports of major and everyday experiences of discrimination were found for a higher proportion of African Americans (46.06% and 45.34%, respectively) and Black Caribbeans (38.50% and 46.98%, respectively) than Whites (6.89% and 6.58%, respectively).
Table 2 shows the association of race/ethnicity with the use of formal and informal helpers. In Model 1, with race/ethnicity as the only correlate, Black Caribbeans are almost 2 times more likely than African Americans and 3 times more likely than are Whites to rely on informal support alone compared with using both professional services and informal support. African Americans are 2.5 times more likely than Whites to not seek help. The introduction of demographic factors, socioeconomic status, and type of problem had little influence on these findings (Models 2, 3, and 4). With the addition of the social network variables in Model 5, the difference between Black Caribbeans and African Americans on use of informal support alone was no longer significant. To determine which variable might account for this change, the social network variables were added to the model one at a time. The relative risk ratio (RRR) and p-value for the relationship between African Americans and Black Caribbeans did not substantially change with the addition of the number of family helpers (RRR = 2.00, p=.048), subjective closeness to family (RRR = 2.01, p = .051), or subjective closeness to friends (RRR = 2.00, p = .046). However, the difference between African Americans and Black Caribbeans was no longer significant with the addition of frequency of contact with family (RRR = 1.88, p = .065) and frequency of contact with friends (RRR = 1.92, p = .064). That is, differences between African Americans and Black Caribbeans in the use of informal support alone are largely accounted for in this study by differences in the frequency of contact with family and friends. Specifically, greater contact is associated with a lower likelihood of relying exclusively on informal support. African Americans have more contact with family and friends than Black Caribbeans.
Finally, Models 6 and 7 were constructed by the separate addition of major and everyday experiences of race-related discrimination. No significant changes were found in Model 6 with the addition of major discrimination. However, when everyday discrimination was added in Model 7, the relationship between Whites and African Americans on the likelihood of not receiving help was no longer statistically significant. On the other hand, Black Caribbeans were still found to be more likely than Whites to rely on informal support alone even after controlling for all other variables, including racial discrimination
Table 3 presents the results of the multinomial logistic regression analyses for the other variables. Demographic and socioeconomic factors are unrelated to source of assistance used. However, frequent contact with friends is associated with a lower likelihood of relying on professional services alone, although more frequent contact with family is associated with a lower likelihood of relying on informal support alone or not receiving help at all. As compared with older adults with nonphysical problems, older adults with a physical health problem were less likely to rely on informal support alone or to not receive any help at all, and more likely to use both professional services and informal support. Bivariate comparisons (Table 4) showed that relying on professional services only was reported by a higher proportion of older adults who were experiencing distress because of an emotional problem (12.47%), informal support alone was used by more respondents experiencing economic problems (42.86%), and using both professional services and informal support was reported by nearly equal percentages of those experiencing an interpersonal problems (50.60%), emotional problems (57.67%), or the death of a loved one (53.53%).
The findings from this study contribute to our understanding of racial/ethnic differences in help-seeking behaviors. One question addressed in this research asks how race and ethnicity is associated with help seeking for a personal problem. Consistent with prior research (Black et al., 1998; Norgard & Rodgers, 1997; Peng et al., 2003), our findings showed that, even when analyses controlled for differences in social support and experiences of major race-related discrimination, African Americans were less likely than Whites to receive help. However, this difference lost statistical significance when analyses controlled for the experience of everyday discrimination. This finding is consistent with previous research on stress and coping and the differential effects of major and everyday events; further, this finding supports assertions that racial discrimination is associated with professional service use (Smedley et al., 2003). However, the finding that African Americans were less likely than Whites to receive help of any kind (i.e., informal and formal) suggests that discrimination may be associated with help-seeking efforts more broadly. This notion is somewhat surprising given that support from informal sources is often cited as a means of coping with racial discrimination and a way of compensating for limited access to professional services. It may be the case that the older adults who had experienced discrimination had adopted a more self-reliant attitude regarding help seeking, which predisposed them to engaging in self-care behaviors.
This relationship of discrimination and help-seeking actions did not extend to differences between Black Caribbeans and African Americans or between Black Caribbeans and Whites, suggesting that experiences of racial discrimination may not have a universal or even similar relationship to the help seeking behavior of all Black Americans (Williams et al., 2008). These questions regarding the potential relationship between racial discrimination and use of informal support for personal problems are deserving of more study.
Indeed, although this study found that racial discrimination and social support were two ways in which race was related to help-seeking behavior, other potential explanations that were not examined may exist. In particular, stigma around mental health issues has been found to influence help seeking among African Americans (Alvidrez, 1999; Snowden, 2001). Stigma may also be more salient for some types of problems than for others. However, respondents in this study were not asked about stigma in relation to specific problems or their help-seeking efforts in general. Further, issues arising from the sample (see discussion in Limitations section) made a more detailed examination of specific problem types impossible.
In this study, not receiving help did not necessarily indicate unmet need. Prior research on the use of professional and informal supports for major health problems and mental disabilities reflected situations that differed substantially from this study’s focus on stressful personal problems. For circumstances involving major health problems and mental disabilities, lack of both professional and informal assistance constitutes unmet need for care. Further, as Krause (1990) observed, not seeking help from professional and informal sources may be a reasonable self-care response to problems that older adults can manage without assistance. This study cannot specifically identify self-care responses. Nonetheless, the present finding that African Americans are less likely to receive help of any kind and that this pattern of service use appears to be related, at least in part, to experiences of racial discrimination underscores the need for additional research that distinguishes between appropriate use of self-care behaviors and situations involving true, unmet need.
Black Caribbeans were more likely to receive help exclusively from informal support sources. In comparison to African Americans, this use of informal support was accounted for by differences in frequency of contact with family and friends (Model 5). In other words, because greater frequency of contact with family and friends was associated with an increased probability of using both professional and informal support, less frequent contact with family and friends among Black Caribbeans was associated with an increased likelihood of relying exclusively on informal supports. This is likely due to the role that family and friends play in linking older adults to professional services. However, differences between Black Caribbeans and Whites in the use of informal support remained significant even after controlling for frequency of contact with family. Ethnographic work indicates high levels of geographic dispersion among many Black Caribbean extended families (Bashi, 2007; Foner, 2001), which results in less frequent contact with family members. Research in geographic dispersion has indicated that Black Caribbean extended families may be widely dispersed geographically with family members residing in locales as far-flung as Brooklyn (New York), London, and the country of origin (Bashi, 2007; Foner, 2001). Geographic dispersion likely influences family members’ abilities to facilitate access to professional services for older adults. At the same time however, Black Caribbeans, particularly those who are recent immigrants to the United States, may rely heavily on family during their transition and acculturation. In this study, 61.54% of Black Caribbeans were born outside of the United States as compared with only 0.44% of African Americans and 2.17% of Whites. Given this finding, more research should focus on how immigration affects access to social networks and, by extension, the potential impact of immigration on the extent and frequency of contact with family members, and immigration’s contribution to within-group heterogeneity in the help-seeking experiences of Black Americans.
Another research question addressed in this study asked what combination of professional services and informal supports older adults used when faced with a serious personal problem. Overall, the findings indicated that older adults in this sample relied heavily on informal networks for support when facing a serious personal problem or crisis. This finding is not only consistent with previous research indicating that family and friends play a substantial role in the long-term care of older adults, but also verifies similar help-seeking patterns for problems other than physical health issues (Cohen et al., 2001; Davey et al., 2005; Nordberg et al., 2005; Penning, 2002). In addition, as opposed to substituting one type of help for another, the findings from this study also confirm previous research that has demonstrated the complementary relationship of professional services and informal support, whether family or friend (Caldwell et al., 1996; Cohen et al., 2001; Miner, 1995). Further, this finding demonstrates the importance of examining the intersection of professional services and informal support as well as the factors associated with the use of each source of help.
This study also sought to determine what demographic, socioeconomic, and social support factors were associated with help seeking for a stressful personal problem. Similar to the finding of prior research, this study found that the potential for support (available helpers) and affective closeness were not as important to securing assistance as were actual contact (i.e., greater frequency) with family and friends (Cohen et al., 2000; Thoits, 1995). The findings also indicate that family and friends had different roles in the process of securing assistance for older adults. Contact with family was associated with a lower likelihood of relying exclusively on informal support, whereas contact with friends was associated with a lower likelihood of relying on professional services only. Given the cross-sectional nature of the study, we can only speculate about the sequence of events and directionality of effects. However, these findings may reflect differences in help-seeking pathways and different forms of assistance received from family versus assistance received from friends. Moreover, these findings are consistent with other research that has shown that family and friends tend to play different supporting roles in the care of older adults (Cohen et al., 2000; Litwak, 1985). Family members may provide initial and direct help to the older person, as well as facilitate access to professional services when skilled assistance is needed. In contrast, when family support is limited, friends may be the initial contact for assistance. Friends may have a more limited role in providing direct support, and instead facilitate contact with professional service providers. Alternatively, the initial contact and source of assistance may involve helping professionals (e.g., social workers) who encourage the older person to establish contact with available network members (i.e., friends).
As noted previously, existing research on help-seeking behaviors among older adults has focused primarily on long-term care and physical illness. As a departure from this literature, Krause’s model focuses instead on stressful life events, multiple sources of care, health behaviors, and diverse coping responses. The present study suggested that help seeking for specific types of problems looks different and engages different sources of care. Specifically, older adults with a physical health problem were more likely to rely on a combination of professional services and informal support whereas those with nonphysical problems were more likely to rely on informal support alone or to not receive help. These findings confirm previous conceptions of the particular task-specific roles filled by various sources of help (Litwak, 1985).
This study has several limitations that should be acknowledged. Most important, cross-sectional data limits the ability to understand the nature of help seeking as a process. It is impossible to determine whether those who used both professional services and informal support used these sources of help concurrently or consecutively. In addition, causal inferences are not possible and issues with respect to the timing of events and hypothesized effects are unresolved. This study, as well as others in this area, assumes that discrimination events occur prior to reports of help seeking. There is some evidence to support this supposition, including research that has suggested discrimination, or at least the perception of discrimination, is a fairly common experience, and that the association of everyday discrimination with psychological distress is comparable to the psychological distress of major stressful life events (Kessler et al., 1999). The development of prospective studies of discrimination experiences and help-seeking behaviors for life problems would provide stronger evidence of a causal link (Williams et al., 2008).
Further, for three subgroups of older adults in this sample—those who relied solely on professional services, relied solely on informal support, or received no help—it is impossible to determine the extent to which their needs were met. Indeed, as Krause points out, not seeking help may be the right decision for a particular situation and represent an appropriate self-care response (Krause, 1990). We also cannot determine the type of help older adults received for each type of problem. For example, when a loved one dies, the older adult may seek help with making funeral arrangements, sorting out the loved one’s personal belongings, or carrying out other practical, concrete tasks. On the other hand, the older adult might also seek help with the physical and emotional problems that result from grieving the loss of a loved one or other distress he or she experiences related to the loss. In reality, help seeking likely encompasses not only instrumental support for practical concerns but also emotional support as well as informational support for problems that require specific professional services. Future research on the trajectory and combination of help-seeking efforts and strategies would be useful in addressing these questions.
A related limitation is the time frame of both the problem and the response to the problem. Respondents were asked to talk about a problem that may have occurred at any point in their lifetime. Most responses were retrospective reports of a problem that happened more than a year before the interview, and some problems may have been experienced when the respondent was younger than age 55. Although allowing a retrospective approach enabled us to consider aspects of a problem most salient to the older adult, the reliability of the details about the problem was subject to potential recall bias. Further, the results are limited to examining help-seeking behaviors in the one example the respondent selected.
Another limitation of this study is the relatively small number of older adults who indicated relying solely on professional services. From a substantive perspective, the exclusive reliance on professionals may suggest these adults have deficits in informal sources of support and potential unmet need. Thus, the small numbers of older adults who relied solely on professionals may indicate that this group is disadvantaged in terms of support resources. From a statistical standpoint, the small number of cases for some categories may not only influence the reliability of some results but also limit the number of variables included in the models. For example, a variable for insurance coverage might be associated with access to professional services, but was not included in our models. Older adults without coverage or with insufficient coverage may rely more on informal supports or be less likely to receive professional care. Further, differences in help-seeking behaviors may also be related to racial/ethnic differences in insurance coverage. Bivariate analysis indicated no difference in the use of professional services and informal support by uninsured persons or those with either private or public insurance coverage (χ2 = .66, p = .619). However, a higher proportion of White respondents had private insurance (80.92% compared with 58.81% of African Americans and 66.63% of Black Caribbeans) whereas more African Americans and Black Caribbeans reported having public insurance (33.7% of African Americans and 26.16% of Black Caribbeans as compared with 15.37% of Whites) or having no insurance (7.49% of African Americans and 7.2% of Black Caribbeans compared with 3.72% of Whites; χ2 = 7.91, p < .001). However, overall only 64 respondents were uninsured and only one uninsured respondent relied solely on professional service providers. Given the few number of uninsured respondents, we could not include insurance coverage as a variable in the multivariate analysis. Further research should explore the role of insurance coverage in the use of professional services and informal assistance by older adults, as well as the role of insurance coverage in racial/ethnic differences in help-seeking patterns and access to services.
This study enhances our understanding of racial and ethnic differences in help seeking among older adults by examining differences among Black Americans as well as between Blacks and Whites. Racial differences in the use of professional services and informal support were found, as well as in reported racial discrimination and its relationship to help-seeking behaviors. These findings also verified that Black Americans are not a homogenous group, and demonstrated the important ethnic differences that emerged regarding older adults’ use of professional and informal assistance for personal problems.
Including use of both professional services and informal support in this study confirms that informal support fills an important role in the lives of older adults, and suggests that informal support is critical to both the direct response to a problem and in facilitating access to professional services. Our preliminary attempt to examine when and how older adults use both sources of help provides a more complete understanding of the support needs of older Americans. In addition, although limited to the one example selected by the respondent, this study expands the realm of help-seeking efforts beyond the issues of long-term care and physical health. Although physical care is undoubtedly important, older adults also face stressors in other life domains. Understanding patterns of responses to and consequences of these stressors provides greater insight into the full spectrum of help-seeking behaviors of older adults.
Informal networks are recognized as the first and most effective support resources that people turn to in managing stressful personal problems. In many cases, using informal support is an appropriate course of action and many life problems are effectively handled with the assistance received from family or friends. The finding that older Black Caribbeans are more likely to rely solely on informal support but have less contact with family suggests this group has particularly resilient informal support networks or the potential for greater burden to caregivers. Informal networks are also important in facilitating older adults’ access to professional service providers at times when specialized assistance is needed. However, some efforts to secure professional services are hampered or curtailed by barriers such as inadequate access, lack of knowledge, lack of availability, and problems with acceptability of professional services. Older Black Caribbeans’ sole reliance on informal supports may reflect difficulties in these areas as well as possible cultural differences affecting the likelihood of using professional services for personal problems. Further, because contact with family is an important link to professional services, the lower rates of family contact among older Black Caribbeans (the result of network disruptions associated with immigration) may disadvantage this group of older adults in securing needed services.
On the other hand, the absence of any form of support to help older Americans respond to personal problems raises concerns and emphasizes the need to determine whether patterns of nonuse reflect an appropriate course of action given their own coping skills and abilities (i.e., self-care) or whether older adults are encountering problems in accessing informal and professional support resources and a genuine need for assistance. In this instance, the mediating role of the experience of racial discrimination is particularly disconcerting, and is an important area for future research.
Considering the set of network and relationship characteristics as a whole, it is clear that contact with family and contact with friends are both associated with professional and informal support for personal problems. The present findings reinforced prior work indicating that informal and formal support resources function in conjunction with one another. In addition, support from friends was as important as assistance from family. Future research should explore the availability of family and friends and the interactions of these informal helpers with professional helpers to determine the most effective strategies for providing complementary services that meet the needs of older clients.
Woodward, A. T., Chatters, L. M., Taylor, R. J., Neighbors, H. W., & Jackson, J. S. (2010). Differences in Professional and Informal Help Seeking among Older African Americans, Black Caribbeans and Non-Hispanic Whites. Journal of the Society for Social Work and Research, 1(3),124-139.