Previous research has documented a high prevalence of depressive symptoms in elderly Korean immigrants (Donnelly & Kim, 2008; Jang, Kim, & Chiriboga, 2005). Many elderly Korean immigrants have difficulty adjusting due to language barriers and sociocultural differences. The sociocultural environment affects the way individuals perceive and express feelings of distress and depression. Koreans do not tend to openly share their personal and family matters but rather attempt to resolve conflicts and emotional distress internally by suppressing their feelings. Acculturation, viewed as a multidimensional process in which one maintains his or her own original culture while also adopting aspects of the new cultural group (Berry, 1997), has a significant positive or negative relationship with mental health among immigrants (Abbott et al., 2003; Cuellar, Bastida, & Braccio, 2004; Wilmoth, & Chen, 2003). Research indicates that the incidence and prevalence of depressive symptoms are higher among immigrants, especially in less-acculturated immigrants than in U.S.-born and more acculturated groups (Abbott et al., 2003; Gonzalez, Haan, & Hinton, 2001; Jang et al., 2005; Wilmoth & Chen, 2003). In contrast, some studies reported more depressive symptoms in Mexican immigrants with greater acculturation (Cuellar et al., 2004; Heilemann, Frutos, Lee, & Kury, 2004).
Maintaining one’s original ethnic and cultural identity can be a resource for coping with stress (Berry, 1997). A study found a higher prevalence of depressive symptoms in marginally acculturated (to either Korean or American culture) Korean immigrants than in those with higher acculturation to either American or Korean culture (Choi, Miller, & Wilbur, 2007). Several factors (e.g., educational level, preparation for immigration, geographical region) might influence the acculturation process. Immigrants who came to the United States for family reunion purposes have poor preparation for immigration (e.g., lack of language skills, lack of understanding of American culture) and thus have difficulty adjusting to the host country (Jang et al., 2005).
The purpose of this study was to identify whether living in a different sociocultural environment and adapting to that environment has any effect on mental health in Korean older adults. The interrelationships among acculturation, geographical location, gender, and depressive symptoms in community-dwelling elderly Korean immigrants and elderly Koreans were examined. Specific aims included assessing the relationship between acculturation and depressive symptoms in elderly Korean immigrants and assessing the effect of geographical location (Korea versus United States) and gender on depressive symptoms in elderly Korean immigrants and elderly Koreans.
The environmental changes (e.g., better conditions for women) and role changes (e.g., earning income outside of the home) that immigrant Korean women experience in the host country might influence their depressive symptoms. No studies compared gender differences in depressive symptoms specifically between elderly Korean immigrants and elderly Koreans. Considering the increasing numbers of elderly Korean immigrants in the United States and the cultural response to mental health issues (e.g., mental health problems as a family stigma in Korea), earlier identification of depressive symptoms and more timely intervention are important.
This study is based on Berry’s (1997) acculturation theory. Acculturation, a process of adaptation, begins with the experience of two cultures that are completely different. Berry (1997) identified four individual acculturation strategies: integration (i.e., maintaining a positive relationship with both a new culture and the original culture), assimilation (i.e., adoption of a new culture but rejection of the original culture), separation (i.e., maintaining the original culture but rejecting the new culture), and marginalization (i.e., rejection of both the new and original cultures). Studies have reported higher prevalence of depressive symptoms in Korean immigrants who reject both the new and original culture (marginalized) compared with those who fall within the categories of integration, assimilation, and separation (Choi et al., 2007; Jang et al., 2005). Korean immigrants with higher educational levels tend to be more acculturated and have a higher socioeconomic status (Kim & Chan, 2004; Lee, Sobal, & Frongillo, 1999).
When immigrants face a new host society, they experience many challenges, such as changes in the physical environment, culture, social status, language, economics, and lifestyle behaviors more generally. The changes immigrants face on a daily basis can be barriers for acculturation for some people who have less education and are less prepared for immigration. Koreans, especially women, tend to be passive in their environment. Silverstein and Lynch (1998) found that women appear to have higher rates of depression than men, probably due to social limitations placed on them. The majority of elderly Korean women devoted their lives to being housewives, raising children, cooking, and taking care of their homes. They have not had the opportunity to focus on self-development. Thus, they describe their later life as boring and lonely (Sin, LoGerfo, Belza, & Cunningham, 2004). Because of this, elderly Korean women might be more vulnerable to depression than elderly Korean men. Research (Yeung & Schwartz, 1986; Zheng & Berry, 1991) indicates that the greater the stress of acculturation, the higher the risk for psychological problems, particularly in the initial months of life in the new host society combined with low educational levels and poor preparation for immigration.
A cross-sectional design was used for this study to assess the interrelationships among acculturation, geographical location, gender, and depressive symptoms in community-dwelling elderly Korean immigrants and elderly Koreans. This collaborative study was approved by a University Human Subjects Review Committee. Agreement for data collection was received from each institution both in the United States and Korea. Informed consent (written in Korean) was obtained from each participant in both groups.
Sample and Data Collection
A convenience sample of 88 elderly Korean immigrants was recruited from Korean senior centers and senior apartments in Washington State. The researcher (M.-K.S.) met presidents of senior centers ahead of data collection and received permission to conduct the study in the senior centers. Some senior center attendants introduced the researcher to other elderly Korean immigrants who did not attend the senior centers and lived in senior apartments. (Note. Elderly Korean immigrants tend to live together in senior apartments.) Data were collected from April to May 2005 by the researcher and a trained research assistant. The number of participants recruited was limited because of the restricted funding available in the United States.
A total of 295 elderly Koreans were recruited from senior centers and social welfare centers in Seoul, Korea. The research team in Korea obtained cooperation from the directors/managers of the senior centers and social welfare centers. Senior centers in the United States and social welfare centers in Korea help Korean older adults with developing a social network. Data in Korea were collected from June to July 2004 by trained research assistants. Inclusion criteria for participants in both Korea and the United States included: age 65 and older and Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) score of 23 or higher.
Demographic characteristics were assessed with standard self-report questions about age, gender, marital status, education, living status (i.e., alone, with spouse, with others), and health status (i.e., poor, fair, good, excellent). Acculturation status was measured by using the number of years in the United States. Duration of residence in the United States has been shown to be a valid and reliable measurement of acculturation (Goel, McCarthy, Phillips, & Wee, 2004; Juon, Kim, Han, Ryu, & Han, 2003; Singh & Siahpush, 2002).
The Korean version of the Geriatric Depression Scale-Short Form (KGDS-SF) (Bae & Cho, 2004) was administered in an interview format to measure depressive symptoms of elderly Korean immigrants and elderly Koreans. The KGDS-SF is a translated and back translated form of the Geriatric Depression Scale-Short Form (GDS-SF) by researchers in Korea who are proficient in English. The GDS-SF, drawn from the original 30-item GDS, is a 15-item self-report dichotomous response format (yes/no) with a range of scores from 0 to 15; scores greater than 5 define depression. Higher scores indicate the presence of a greater number of depressive symptoms. The GDS-SF was found to be highly correlated with the original GDS (r = 0.89, p < 0.01) in older adults (Lesher & Berryhill, 1994). The GDS-SF also showed a significant correlation with the Beck Depression Scale (r = 0.84, p < 0.01), establishing concurrent validity (Ferraro & Chelminski, 1996). Reliability estimates of the KGDS-SF tested by a collaborative team in Korea and a researcher in the United States demonstrated high internal consistency (Cronbach’s alpha coefficient = 0.83 and 0.84, respectively).
SPSS version 15.0 was used for data analysis. Descriptive statistics were performed initially to describe the distribution of sample characteristics. Pearson’s product moment correlation analysis was used to assess the relationship between acculturation and depressive symptoms among elderly Korean immigrants. Two-factor analysis of variance was used to assess the effect of geographical location and gender on depressive symptoms in elderly Korean immigrants and elderly Koreans. The critical value for statistical significance was set at a p level <0.05.
A total of 88 elderly Korean immigrants and 295 elderly Koreans participated in this study. The mean age of elderly Korean immigrants in this study was 76 (SD = 6.48 years); the majority were married (60.2%) with good self-reported health status (56.8%). The mean age of elderly Koreans was 73 (SD = 4.77 years); the greatest proportion were married (60.3%) and reported good health status (37.6%). More elderly Korean immigrants than elderly Koreans had higher education (college/graduate) (23.9% versus 6.1%) and lived alone (39.8% versus 19.3%) (Table 1).
Table 1: Demographic Characteristics of the Sample
None of the demographic factors (e.g., age, gender, marital status) had a significant relationship with depressive symptom scores in either elderly Korean immigrants or elderly Koreans. However, educational level had a significant negative correlation with depressive symptom scores in elderly Koreans (p < 0.01). Self-ratings of health status had a significant negative correlation with depressive symptom scores in both elderly Korean immigrants (r = −0.36, p ≤ 0.01) and elderly Koreans (r = −0.42, p ≤ 0.01).
Acculturation and Depressive Symptoms
The mean number of years elderly Korean immigrants had lived in the United States was 17 (range = 1 to 35). Acculturation (i.e., years living in the United States) had no significant correlation with depressive symptom scores (r = 0.01, p = 0.94).
Effects of Geographical Location and Gender on Depressive Symptoms
A two-factor analysis of variance indicated a significant main effect of gender on depressive symptoms (F = 4.07, p = 0.04). No significant interaction was found between geographical location and gender in predicting depressive symptoms (F = 0.92, p = 0.34). Women had higher depressive symptom scores than men in both groups (elderly Korean immigrants: women, mean = 6.03, SD = 3.57, men, mean = 5.29, SD = 2.80; elderly Koreans: women, mean = 6.49, SD = 3.87, men, mean = 5.69, SD = 3.70). More women in Korea had either moderate or severe depressive symptoms than women in the United States (66.1% versus 56.4%). Mean depressive symptom scores in men were higher in elderly Koreans than in elderly Korean immigrants (Table 2).
Table 2: Depressive Symptom Scores Among Elderly Korean Immigrants (n = 88) and Koreans (n = 295)
The unweighted least squares analysis was performed to adjust the confounding effect of gender (from unequal distribution of gender in each group) on geographical location. The unweighted least squares analysis yielded the same results as two-factor analysis, with a significant main effect of gender and no significant interaction between geographical location and gender on depressive symptoms. The weighted least square regression was performed because of various standard deviations in the depressive symptom scores and indicated similar results as the unweighted least square analysis: geographical location, t = −1.04, p = 0.30; and gender, t = 2.04, p = 0.04. Geographical location had no significant main effect on depressive symptoms.
Consistent with previous research, health status had a significant relationship with depressive symptoms in both elderly Korean immigrants and elderly Koreans (Noel et al., 2004; Sin et al., 2004). Chronic diseases are associated with diminished quality of life and greatly increased health care costs in older adults (Chan et al., 2002; Sin et al., 2004). Poor health is not an inevitable consequence of aging. Rigorous studies are needed to determine ways to maintain and promote good health status and minimize years of experiencing chronic illness in older adults.
Educational level had a significant relationship with depressive symptoms in elderly Koreans. Elderly Koreans with higher education had fewer depressive symptoms; this has been supported in other studies (Chiao, Weng, & Botticello, 2009; Jeon, Jang, Rhee, Kawachi, & Cho, 2007; Kim, Shin, Yoon, & Stewart, 2002; Lee & Shinkai, 2005). Elderly Koreans in this study had lower educational levels than elderly Korean immigrants in general. More targeted interventions for those with lower educational levels may be needed to promote their mental status.
Acculturation and Depressive Symptoms
Acculturation, defined as years living in the United States, had no significant relationship with depressive symptoms among elderly Korean immigrants in this study. Although duration of residence in the United States has proven to be a valid and reliable measurement of acculturation (Goel et al., 2004; Juon et al., 2003; Singh & Siahpush, 2002), it might be more useful to use an acculturation scale that measures other aspects, such as language and media use, foods, and friendship.
Many elderly Korean immigrant participants immigrated to the United States to reunite with their children but were inadequately prepared for the changes they would encounter. Lack of understanding of the host culture, poor English language skills, and no personal transportation limited their daily boundaries to nearby surroundings, minimizing their opportunities for exposure to the host culture. Many of the participants live in low-income senior apartments as a group, which may be one reason for the lack of a relationship between acculturation and depressive symptoms in this study. Maintaining one’s original ethnic and cultural identity had a beneficial effect on depression (Berry, 1997; Choi et al., 2007). However, social and physical isolation from language barriers and living in senior apartments with limited social opportunities might result in limited integration of the host culture, which may directly influence mental health in this particular group (Berry, 1997; Jang et al., 2005; Sin et al., 2004).
Geographical Location and Gender Effect on Depressive Symptoms
When different gender distributions in the United States and Korea were controlled, geographical location did not have any influence on depressive symptoms. Depressive symptoms were highly present in both elderly Korean immigrants and elderly Koreans, consistent with other studies (Donnelly & Kim, 2008; Jang et al., 2005; Shin, Shin, Park, & Yi, 2004). More than half of the study participants in both groups had either moderate or severe depressive symptoms. Among elderly Korean immigrants, 53.4% experienced depressive symptoms (39.8% moderate, 13.6% severe) compared with 63% of elderly Koreans (42% moderate, 21% severe). Elderly Korean immigrants who live in cultural enclaves in a foreign country with a better social welfare system (e.g., monthly stipend, low-income apartment) (Sin et al., 2004) may have less depressive symptoms than elderly Koreans. No participant in this study was taking antidepressant agents or using any traditional or complementary/alternative treatments for mental health.
Koreans tend to have passive personalities. Maintaining emotional balance is considered a virtue and a sign of maturity in Korean culture (Sin et al., 2004). Thus, Koreans tend to suppress their feelings when they encounter a disruption in their usual person-environment interaction. Since the majority of elderly Koreans had depressive symptoms in the screening test, further timely assessment and interventions are critical. An understanding of the complex interplay of acculturation and psychological status, as well as individuals’ preferred way to cope with depressive symptoms, would be useful for the development of appropriate health-promoting interventions and would enable health care providers to better serve this minority population.
Gender had a significant effect on depressive symptoms. Sixty-five percent of the Korean participants were women compared with 44% of the Korean immigrants. Women had higher depressive symptom scores than men in both groups. According to national data (National Institute of Mental Health [NIMH], 2003), nearly twice as many women (12%) as men (7%) are affected by a depressive illness each year in the United States. The reasons for the higher prevalence of depression in women are uncertain, but possible causes include stressful life experiences and hormonal changes (NIMH, 2003). Immigrant Korean men are more likely to be depressed by work-related problems (e.g., income, salary, occupation), whereas women are more likely to be depressed by relationships with family, relatives, and neighbors (Koh, 2003). Poor economic status and low education contributes to late-life depression in older adults in Korea (Jeon et al., 2007; Kim et al., 2002; Kim, Stewart, Shin, Yoon, & Lee, 2004; Lee & Shinkai, 2005), as found in this study. Factors influencing mental health of older adults of both genders might differ from those influencing younger adults, which might be an interesting project to better help this population.
A higher percentage of elderly Korean women had either moderate or severe depressive symptoms compared with men. One study reported a high rate of depression in Korean women (Shin et al., 2004). Korean society is based on a patriarchal structure in which women’s roles and positions are limited, especially for the older generation. Expectations associated with social roles differ for men and women in Korea. Socially defined limitations placed on Korean women might contribute to the high rate of depression (Shin et al., 2004). Women’s social position and responsibility might also influence the higher rates of depression among elderly women in Korea (Shin et al., 2004). Intervention studies to modify higher depressive symptoms among women might be needed to promote women’s health.
Although elderly Korean immigrants are a fast growing minority group in the United States (U.S. Census Bureau, 2004), studies on this population are limited. Elderly minorities are often excluded from research studies (Ell et al., 2007; Knight & Houseman, 2008; Mastel-Smith, McFarlane, Sierpina, Malecha, & Haile, 2007). In this study, depressive symptoms were highly present in both elderly groups. Further assessment of depressive symptoms and timely interventions might benefit these groups. More culturally based approaches targeting elderly Koreans with limited access to the host country are desperately necessary. A nationwide approach, such as improved social welfare systems for older adults in the United States (e.g., monthly stipend, health insurance, independent low-income housing, using older adults for low-pay or voluntary work) might greatly benefit the mental health status of elderly Korean immigrants (Hao, 2008; Wahrendorf, Ribet, Zins, & Siegrist, 2008; Wong, Yoo, & Stewart, 2007). For example, older Korean immigrants living with adult children had lower overall psychological well-being compared with those who lived alone (Wong et al., 2007). The majority of elderly Korean immigrants (86%) in this study lived independently from their children in low-income apartments.
According to the World Health Organization’s World Health Survey on adults age 18 and older (Moussavi, Chatterji, Verdes, & Tandon, 2007), depression has a greater impact on overall health than some chronic illnesses, such as angina, arthritis, asthma, and diabetes, and has a high degree of association with disability. Despite its significant impact on health, depression is unrecognized and untreated in many cases, especially in minority populations. Assessing the mental health status of people from a different culture and language is challenging. Greater emphasis on cultural diversity in the nursing workforce may result in more effective management of mental health issues in minority populations.
This study provides useful baseline data on mental health status of Korean older adults for future studies. An understanding of acculturation-related psychological status and how people from different cultures respond to the acculturation process and cope with depressive symptoms might help health care providers deliver culturally relevant services. More studies on factors influencing depressive symptoms in this age group might be helpful to better assist this group. Many elderly Koreans seek health care mainly for apparent physical signs and symptoms. Mental health is often ignored in this generation. They may not be aware of signs and symptoms of depression or the consequences of depression on physical health status. Education on depression can be a useful strategy for older Koreans to increase their awareness of the importance of mental health.
Use of culturally relevant instruments for assessment of mental health could provide more accurate diagnoses of depression. For example, use of instruments that use a Likert scale or have more response selections, rather than dichotomous (yes/no) responses, could be considered, given the nature of Koreans to maintain a moderate level of emotion. Feeling medium or so-so might suggest the capability of stability in Korean life. When designing any community-based program, interventions that can enhance older adults’ health status are needed. Furthermore, helping older adults properly cope with depressive symptoms needs to be considered.
Some elderly Korean immigrants expressed difficulty answering some of the depressive symptom questions due to the dichotomous response format, which can be a weakness of the GDS in some situations. Traditionally, many Koreans are not used to expressing their feelings in a definite yes/no format. For example, some questions, such as whether they are in good spirits most of the time, feel happiness most of the time, and find life very exciting, were difficult for elderly Korean immigrants to answer in a yes/no format. It is assumed that the difficulty of answering in a yes/no format is not limited only to elderly Korean immigrants. Use of other questionnaires to measure depressive symptoms should be considered to better assess mental status.
The limitations of this study include sampling method, design, unequal sample sizes, and methods used to measure acculturation. The use of convenience sampling and the comparison of unequal numbers of elderly Korean immigrants and elderly Koreans limit the generalizability of the study findings. However, it should be noted that elderly Korean immigrants were recruited from a smaller pool than elderly Koreans. Elderly Korean immigrants were recruited from diverse locations, including three senior centers and two senior apartments in Washington State. The findings from this study may be generalizable to elderly Korean immigrants in Washington State who meet the inclusion criteria of this study and live in a similar environment as these participants. Further interventions will be targeted toward those who are accessible (e.g., those who attend senior centers, live senior apartments, and attend Korean churches). In addition to these limitations, further assessment of recent negative life events (e.g., loss of significant others) and other factors that may affect mental health may be useful to better understand participants’ emotional status.
Although unequal numbers of elderly Korean immigrants and elderly Koreans participated in this study, depressive symptoms were assessed using the same instrument and protocol between the two countries (Korea and United States). Cross-sectional design limits the assessment of mental status to one time point. Assessing depressive symptoms longitudinally might better reflect the psychological status of elderly Koreans. Also, because the dichotomous nature of the depression instrument limits response options, use of other instruments might help obtain more accurate data.
Acculturation had no relationship with depressive symptoms in this study. Years of living in the United States may not be sufficient to accurately measure acculturation status. Use of a multidimensional acculturation instrument (e.g., the Suinn-Lew Asian Self-Identity Acculturation Scale; Suinn, Khoo, & Ahuna, 1995) that includes diverse aspects (e.g., language and media use, friendship, area of residence, ethnic self-identity) is recommended in future studies.
This study reported no significant relationship between acculturation and depressive symptoms in elderly Korean immigrants. Assessment of acculturation from a multidimensional conceptualization might more accurately measure the concept than number of years living in the United States. Depressive symptoms were highly present in both elderly Korean immigrants and elderly Koreans. Further assessment of depressive symptoms and development and implementation of timely interventions are necessary. Gender had a significant influence on depressive symptoms, but geographical location did not. Elderly women had higher depressive symptoms than elderly men in both groups. Understanding the factors influencing depressive symptoms in this age group and coping mechanisms used by each gender might help health care providers better serve this group. This first cross-cultural comparison study among elderly Korean immigrants and elderly Koreans provides useful baseline data for future studies for Korean older adults.
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Demographic Characteristics of the Sample
||Elderly Korean Immigrants (n= 88)
||Elderly Koreans (n= 295)
|Mean age (range)
||76 (65 to 88)
||73 (65 to 84)
|Gender, n (%)
|Marital status, n (%)
|Educational level, n (%)
| No schooling
| Elementary school, middle school, high school
|Living situation, n (%)
| With spouse
| With others
|Health status, n (%)
Depressive Symptom Scores Among Elderly Korean Immigrants (n = 88) and Koreans (n = 295)
|Elderly Korean immigrants
|Elderly Korean immigrants versus Elderly Koreans