edicine and Rehabilitation
Archives of Physical M journal homepage: www.archives-pmr.orgArchives of Physical Medicine and Rehabilitation 2013;94:193-5
BRIEF REPORT
Gender, Health Ambiguity, and Depression Among Survivors ofFirst Stroke: A Pilot Study
Michael J. McCarthy, PhD,a Karen S. Lyons, PhD,b Laurie E. Powers, PhD,c
Elizabeth A. Bauer, BSa
From the aSchool of Social Work, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH; bSchool of Nursing, Oregon Healthand Science University, Portland, OR; and the cSchool of Social Work, Portland State University, Portland, OR.
Abstract
Objective: To investigate the association between health ambiguity and depressive symptoms among stroke survivors and whether survivor
gender moderates this association.
Design: Cross-sectional survey study.
Setting: General community.
Participants: Survivors of first stroke (NZ36) recruited through provider referral, support groups, and print and Web-based sources.
Interventions: Not applicable.
Main Outcome Measures: Depressive symptoms as measured by the Patient Health Questionnaire-9.
Results: Health ambiguity (βZ.984, P<.001), gender (βZ1.010, P<.01), and the interaction of the 2 variables (βZ�1.269, P<.05) were
significantly associated with depressive symptoms. Simple slopes tests indicated that the association between health ambiguity and depressive
symptoms was stronger for male versus female survivors.
Conclusions: Gender and health ambiguity impact survivor depressive symptoms, independently and in conjunction with one another. Results are
promising, and further research with larger samples and more comprehensive statistical models is needed to confirm these findings.
Archives of Physical Medicine and Rehabilitation 2013;94:193-5
ª 2013 by the American Congress of Rehabilitation Medicine
Approximately every 40 seconds, someone in the United Statesexperiences a stroke, and at any given moment, there are 7 millionstroke survivors contending with the physical, social, andpsychological challenges stemming from the acute event.1 Ofthese psychological challenges, depression has been identified asthe most common, affecting approximately 33% of the survivorpopulation.2 Survivor depression is painful in itself and has beenlinked with poor outcomes such as low engagement in rehabili-tation activities and a 4 times greater risk of early mortality(hazard ratioZ4.4, P<.05).3,4 To alleviate survivors’ immediateand longer-term distress, it is important to identify factors asso-ciated with depression following stroke.
A number of studies have examined predictors of depressionamong stroke survivors such as the ability to perform activities ofdaily living (ADL).5 Other more nuanced factors such as health
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this article has or will confer a benefit on the authors or on any organization with which the authors
are associated.
0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Re
http://dx.doi.org/10.1016/j.apmr.2012.07.019
ambiguity (ie, ambiguity about the future with respect to one’shealth)6 have received little attention in the stroke literature. Amongindividuals with other complex neurologic conditions such asmultiple sclerosis, health ambiguity has been strongly associatedwith depression.7 Thus, there is reason to believe that ambiguitymaybe a factor in stroke survivors’ psychological adjustment as well.
Research and theory about gender-based health-related beliefsalso suggest that the effects of health ambiguity on survivoroutcomes may be different for men versus women. Courtney8
articulated a theory of U.S. men’s health in which the masculineideal (ie, that men are strong, independent, self-reliant, in control)gives rise to culturally reinforced beliefs that men should be moreresilient in the face of illness. Ambiguity about the status of one’shealth may threaten these beliefs and ultimately lead to poorerpsychosocial outcomes for men.
This pilot study examined the association between healthambiguity and depressive symptoms among stroke survivors andthe extent to which gender may moderate this association. Wehypothesized that because of gender-based beliefs, the association
habilitation Medicine
Table 1 Characteristics of study sample
Variable Male (nZ20) Female (nZ16)
Race (% white) 80.0 81.3
Education (y) 14.25�2.59 14.44�2.36
Age (y) 59.55�12.69 60.62�17.28
Months since stroke 12.25�12.32 9.00�8.12
ADL impairment 12.05�5.45 10.50�4.45
Health ambiguity 32.69�5.93 31.50�10.41
Depressive symptoms 9.05�5.78 6.39�5.24
NOTE. Values are mean � SD or as otherwise indicated.
194 M.J. McCarthy et al
between health ambiguity and depressive symptoms would bemore pronounced for male survivors than for female survivors.
Methods
Setting and sample
Data for this study were collected for a study investigating thepsychosocial experiences of couples after stroke. Survivors wererecruited over 12 months through 3 health care systems and severalstroke support groups in the Portland,OR,metropolitan area, aswellas through print- and Web-based sources. To be included in theoriginal study, survivors had to be currently in a committed rela-tionship, have experienced stroke between 1 and 36 months prior tothe interview, and be capable of providing informed consent. Intotal, 36 survivors participated in the study (16 women, 20 men).Study activities were overseen by the institutional review boards ofparticipating health care systems, as well as by the institutionalreview board at Portland State University.
Procedure
Eligible survivors completed questionnaires via face-to-faceinterviews. Interviews consisted of the interviewer readingverbatim questions from the measures described below and thenmarking participants’ responses on a paper form. Participants weregiven $50 in appreciation for their time.
Measures
Dependent variableSurvivor-reported depressive symptoms were measured with thePatient Health Questionnaire-9.9 In addition to identifying majorand minor depressive episodes, the Patient Health Questionnaire-9generates a numerical score reflecting depression severity. Totalscores may range from 0 to 27. Cronbach’s alpha for the presentsample was .83.
Independent variablesHealth ambiguity was measured with the ambiguity subscale of theMishel Uncertainty in Illness Scale.6 The original ambiguitysubscale consists of 16 items (eg, I don’t know what is wrong withme; I have a lot of questionswithout answers), with response optionsranging from “1e strongly agree” to “5e strongly disagree.” Threeitems were removed from the original scale for this study becausethe large majority of participants had returned to living in thecommunity at the time of their interview (I do not know when toexpect things will be done to me; It is vague to me how I will managemy care after I leave the hospital ) and because most survivors didnot report experiencing pain resulting from stroke (It is unclear howbad my pain will be). Total scores for health ambiguity may rangefrom 13 to 65. Cronbach’s alpha of the modified measure in thepresent sample was .82.
CovariatesSurvivors’ ability to perform ADL items (eg, cutting food witha knife and fork, bathing, moving from a bed to a chair) was
List of abbreviations:
ADL activities of daily living
measured with 7 items from the Stroke Impact Scale: Version 3.10
Responses for each item range from “1 e not difficult at all” to“5 e could not do at all.” Individual scores were based ona summary of the 7 items, with total possible scores ranging from7 to 35. Cronbach’s alpha for the present sample was .85. Theduration of illness was by survivor self-report.
Statistical analyses
Paired samples t tests in SPSS 19.0a were used to examinedifferences between male and female survivors on key variables.Ordinary least squares regression was used to examine main andinteraction effects of ambiguity and gender on depressive symp-toms. A simple slopes test was used to examine the interac-tion effect.
Results
Sample characteristics stratified by survivor gender are presentedin table 1. No statistically significant differences were observedbetween men and women on any of these characteristics. Multi-variable analyses indicated that, controlling for the duration ofillness (ie, months since stroke) and ADL impairment, healthambiguity was strongly associated with depressive symptoms(βZ.549, P<.001), although gender was not (βZ�.185, PZNS).ADL impairment was marginally associated (βZ.258, P<.10). Ina follow-up model including the same control variables, ambiguity(βZ.984, P<.001) and the interaction of ambiguity and gender(βZ�1.269, P<.05) were significantly associated with depressivesymptoms. Gender was marginally associated (βZ1.010, P<.10).Figure 1 depicts the simple slopes test examining the nature of theinteraction between ambiguity and gender. Results indicated thatthe association between ambiguity and depressive symptoms wasstronger for male survivors than for female survivors.
Discussion
This study suggests that among stroke survivors, health ambiguityhas strong deleterious effects on mental health. Findings alsoindicate that this association may differ according to survivorgender, with ambiguity impacting depressive symptoms in malesurvivors more than in female survivors. Male survivors in theUnited States who subscribe to traditional health-related beliefsmay be accustomed to, and value highly, being in control of theirhealth. Being predominantly older, white, well educated, and incommitted heterosexual relationships, the present sample appearsto be emblematic of this population. For these individuals, loss of
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Fig 1 Simple slopes of depressive symptoms on health ambiguity
moderated by gender. The dotted line indicates male and the solid
line indicates female.
Health ambiguity and depression 195
control due to infirmity caused by stroke could be perceived asa loss of power and prestige.8 These losses, in turn, may result inmore distress and greater depressive symptoms.
Several implications for rehabilitation practice and research aresuggested by this study. Although some degree of health ambi-guity may be unavoidable in the case of stroke and similarillnesses, reducing ambiguity through proactive communicationwith patients and family members may be an effective approachfor reducing survivor distress and, ultimately, for improvingrehabilitation outcomes. Awareness of the harmful, or potentiallybeneficial, effects of traditional gender-based health-relatedbeliefs is also critical. At a minimum, rehabilitation professionalsshould acknowledge that health-related beliefs can have a tangibleimpact on patient outcomes.
Study limitations
The current pilot study included several limitations. First, thesmall sample size precluded performing confirmatory factoranalysis11 on the modified health ambiguity measure to assess thesimilarities and differences between the original and adaptedversions. Although the reliability of the adapted measure wasacceptable in the present sample, confirmatory factor analysisshould be conducted prior to using the modified measure in futurestudies. The small sample size also precluded the examination ofmore comprehensive multivariable models. Second, there waswide variability in time since diagnosis in this study and, thus,participants were likely at different points in recovery with respectto health ambiguity and depressive symptoms. Future studies withnarrower inclusion periods (eg, 6e12 months after diagnosis)would be valuable for examining the relationship between healthambiguity and depressive symptoms. Finally, given the higherprevalence of stroke in minority populations,1 lack of samplediversity may also limit the generalizability of findings to thebroader stroke population.
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Conclusions
This pilot study indicated that gender and health ambiguity impactsurvivor depressive symptoms, independently and in conjunctionwith one another. Future research, with more sociodemo-graphically diverse samples, should further examine how gender-based health-related beliefs affect survivor outcomes, as well asfactors that may protect female survivors from the harmful effectsof health ambiguity such as locus of control, resilience, socialsupport, or a greater willingness to engage in help-seeking behavior.
Supplier
a. SPSS for Windows Version 19.0; SPSS, Inc, 233 S Wacker Dr,11th Fl, Chicago, IL 60606.
Keywords
Depression; Rehabilitation; Stroke; Uncertainty
Corresponding author
Michael J. McCarthy, PhD, College of Allied Health Sciences,School of Social Work, University of Cincinnati, PO Box 210108,Cincinnati, OH 45221. E-mail address: [email protected].
References
1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke
statisticsd2011 update: a report from the American Heart Associa-
tion. Circulation 2011;123:e18-209.
2. Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression
after stroke. Stroke 2005;36:1330-40.
3. Naess H, Lunde L, Brogger J, Waje-Andreassen U. Depression
predicts unfavourable functional outcome and higher mortality in
stroke patients: the Bergen stroke study. Acta Neurol Scand 2010;122:
34-8.
4. Skidmore ER, Whyte EM, Holm MB, et al. Cognitive and affective
predictors of rehabilitation participation after stroke. Arch Phys Med
Rehabil 2010;91:203-7.
5. Hosking SG, Marsh NV, Friedman PJ. Depression at 3 months post-
stroke in the elderly: predictors and indicators of prevalence. Aging
Neuropsychol Cogn 2000;7:205-16.
6. Mishel MH. The measurement of uncertainty in illness. Nurs Res
1981;30:258-63.
7. Kroencke DC, Denney DR, Lynch SG. Depression during exacerba-
tions in multiple sclerosis: the importance of uncertainty. Mult Scler
2001;7:237-42.
8. Courtney WH. Constructions of masculinity and their influence on
men’s well-being: a theory of gender and health. Soc Sci Med 2000;
50:1385-401.
9. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief
depression severity measure. J Gen Intern Med 2001;16:606-13.
10. Lai SM, Perera S, Duncan PW, Bode R. Physical and social func-
tioning after stroke: comparison of the Stroke Impact Scale and Short
Form-36. Stroke 2003;34:488-93.
11. Tabachnick BG, Fidell LS. Using multivariate statistics. 5th edition.
Boston: Pearson Education; 2007.
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