Alternative Writing Assignment Guidelines and Grading RubricPurpose As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role. Course Outcomes This assignment is guided by the following Course Outcomes (COs): 1. Apply advanced practice nursing knowledge to collecting health history information and physical examination findings for various patient populations. (PO 1, 2) 2. Differentiate normal and abnormal health history and physical examination findings. (PO 1, 2) 4. Adapt health history and physical examination skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. (PO 1, 2) The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4). NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week. Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. For example, if you did not attend a debriefing session for Week 3, this written assignment is due the Sunday at 11:59 p.m. MT of Week 4. The standard MSN Participation Late Assignment policy applies to this assignment (please see the course syllabus) Total Points Possible: 25 PointsRequirements: 1. This paper will be graded on the quality of the information, inclusion of evidence-based scholarly resources, use of citations, use of Standard English grammar, and organization based on the required components (see the paper headings and content details below). 2. Submit to the appropriate location in Canvas by 11:59 p.m. MT on Sunday of the week due. 3. The length of the paper is to be no less than 1,500 words, excluding title page and reference list. 4. Create this assignment using Microsoft (MS) Word. You can tell that the document is saved as a MS Word document because it will end in “.docx.” 5. APA format (6th edition) is required in this assignment, explicitly for in-text citations and the reference list. Use 12-point Times New Roman font with 1 inch margins and double spacing. See the APA manual for details regarding proper citation. See resources under Course Resources, “Guidelines for Writing Professional Papers” for further clarification. 6. Organize the headings and content of your paper using the outline below: a. Ident.

1. Alternative Writing Assignment Guidelines and Grading
RubricPurpose
As a family nurse practitioner, you must possess excellent
physical assessment skills. This alternative writing assignment
mirrors the discussion content of the debriefing session and will
allow the student to expand their knowledge of physical health
assessment principles specific to the advanced practice role.
Course Outcomes
This assignment is guided by the following Course Outcomes
(COs):
1. Apply advanced practice nursing knowledge to collecting
health history information and physical examination findings
for various patient populations. (PO 1, 2)
2. Differentiate normal and abnormal health history and
physical examination findings. (PO 1, 2)
4. Adapt health history and physical examination skills to the
developmental, gender-related, age-specific, and special
population needs of the individual patient. (PO 1, 2)
The purposes of this assignment are to: (a) identify and
articulate advanced assessment health history and physical
examination techniques which are relevant to a focused body
system (CO 1), (b) differentiate normal and abnormal findings
with regard to a disease or condition that impacts the body
system (CO 2), and (c) adapt advanced assessment skills if
necessary to suit the needs of specific patient populations (CO
4).
NOTE: You are to complete this alternative writing assignment
ONLY if you had not participated or do not plan to participate
in a debriefing session for the given week.
Due Date: This alternative written assignment is due no later
than the Sunday of the week in which you did not attend the
weekly debriefing session. For example, if you did not attend a
debriefing session for Week 3, this written assignment is due
the Sunday at 11:59 p.m. MT of Week 4.
The standard MSN Participation Late Assignment policy applies

2. to this assignment (please see the course syllabus)
Total Points Possible: 25 PointsRequirements:
1. This paper will be graded on the quality of the information,
inclusion of evidence-based scholarly resources, use of
citations, use of Standard English grammar, and organization
based on the required components (see the paper headings and
content details below).
2. Submit to the appropriate location in Canvas by 11:59 p.m.
MT on Sunday of the week due.
3. The length of the paper is to be no less than 1,500 words,
excluding title page and reference list.
4. Create this assignment using Microsoft (MS) Word. You can
tell that the document is saved as a MS Word document because
it will end in “.docx.”
5. APA format (6th edition) is required in this assignment,
explicitly for in-text citations and the reference list. Use 12-
point Times New Roman font with 1 inch margins and double
spacing. See the APA manual for details regarding proper
citation. See resources under Course Resources, “Guidelines for
Writing Professional Papers” for further clarification.
6. Organize the headings and content of your paper using the
outline below:
a. Identify and briefly discuss the body system selected for the
topic of this paper
b. Discuss the physiology (structure and function) of the body
system including details about the major organ systems (if
applicable)
c. Discuss relevant health history questions (subjective data)
pertaining to the body system
d. Discuss an overview of the objective data and expected
normal physical examination findings for this body system
e. Discuss special physical assessment examination techniques
or procedures specific to assessing this body system
f. Discuss how you might adapt your physical assessment skills
or techniques to accommodate each of the following specific
populations:

3. i. Infant/pediatric
ii. Pregnancy
iii. Geriatric
g. Identify one major disease or disease process that may
significantly impact this body system
h. Discuss the expected abnormal physical examination findings
that may be associated with this disease or disease process
i. Summarize the key points
Preparing the Paper:
1. Select a focused body system from the weekly lesson which
corresponds with the week of the written assignment.
2. Carefully read and review the selected body system in your
course textbooks.
3. Incorporate at least one scholarly peer-reviewed journal
article that relates to the body system. It may be useful to
identify an article that relates to a disease that impacts the body
system.
4. The paper must clearly articulate the relevance of advanced
physical assessment skills, techniques, application of advanced
practice knowledge, and assessment modification (when
necessary) to accommodate for specific patient populations.
5. Provide concluding statements that should summarize key
points of the overall assignment content.
6. In-text citations and reference page(s) must be written using
proper APA format (6th edition).
Category
Points
%
Description
Application of Knowledge, Analysis, and Clarity
10

4. 40%
Student demonstrates application of course knowledge
consistent with the principles of advanced physical assessment;
content is specific to the focus topic, organized, and clearly
presented.
Adapted Physical Assessment Skills to Special Populations,
Disease Process, and Summary
10
40%
Discussed appropriate clinical reasoning and judgment as
evidenced by: adaption of physical assessment skills or
techniques to accommodate special populations;
identified one major disease or disease process and expected
examination findings; and summarized key points
Writing Mechanics and Evidence-based Resources
5
20%
Paper meets the minimum 1,500 word limit (not including the
reference list); Paper is fully supported by evidence from
appropriate Evidence-based, peer-reviewed resources published
within the last 5 years; In-text citations and full references are
provided using proper APA formatting.
Total
25
100
A quality assignment will meet or exceed all of the above
requirements.
Chamberlain College of Nursing
NR509 Advanced Physical Assessment
3
Grading Rubric
Assignment Criteria
Satisfactory

5. Unsatisfactory
10 POINTS
0 POINTS
Application of Knowledge, Analysis, and Clarity
Student demonstrates knowledge consistent with the principles
of advanced physical assessment; content is specific to the
focus topic, organized, and clearly presented.
Student did not demonstrate knowledge consistent with the
principles of advanced physical assessment; content was
missing, unorganized, and unclear.
10 POINTS
0 POINTS
Adapted Physical Assessment Skills to Special Populations,
Disease Process, and Summary
Discussed how to adapt physical assessment skills or techniques
to accommodate special populations; and
identified one major disease or disease process and expected
examination findings; summarized key points.
Student did not adapt physical assessment skills or techniques
to accommodate special populations; and did not
identify one major disease or disease process and expected
examination findings; did not summarize key points.
5 POINTS
0 POINTS
Writing Mechanics and Evidence-based Resources
Paper meets the minimum 1,500 word limit (not including the
reference list); Paper is fully supported by evidence from
appropriate sources published within the last 5 years; and
Evidence-based, peer- reviewed journal article cited; In-text
citations and full references are provided.
Paper does not meet the minimum 1,500 word limit (not
including the reference list)

6. Paper contains no evidence-based practice reference or citation.
Total Possible- Satisfactory = 25 Points
25 Points
0 Points
NR509 January 2018
4
Lesbian, gay, & bisexual older adults: linking internal minority
stressors, chronic health
conditions, and depression
Charles P. Hoy-Ellis
a
* and Karen I. Fredriksen-Goldsen
b
a
College of Social Work, University of Utah, Salt Lake City, UT,
USA;
b
School of Social Work, University of Washington,
Seattle, WA, USA
(Received 30 January 2016; accepted 15 March 2016)
Objectives: This study aims to: (1) test whether the minority

7. stressors disclosure of sexual orientation; and (2) internalized
heterosexism are predictive of chronic physical health
conditions; and (3) depression; (4) to test direct and indirect
relationships between these variables; and (5) whether chronic
physical health conditions are further predictive of
depression, net of disclosure of sexual orientation and
internalized heterosexism.
Methods: Secondary analysis of national, community-based
surveys of 2349 lesbian, gay, and bisexual adults aged 50 and
older residing in the US utilizing structural equation modeling.
Results: Congruent with minority stress theory, disclosure of
sexual orientation is indirectly associated with chronic
physical health conditions and depression, mediated by
internalized heterosexism with a suppressor effect. Internalized
heterosexism is directly associated with chronic physical health
conditions and depression, and further indirectly
associated with depression mediated by chronic physical health
conditions. Finally, chronic physical health conditions
have an additional direct relationship with depression, net of
other predictor variables.
Conclusion: Minority stressors and chronic physical health
conditions independently and collectively predict depression,
possibly a synergistic effect. Implications for depression among
older sexual minority adults are discussed.
Keywords: Sexual orientation; depression; older adults;
minority stress; structural equation modeling
Introduction
The World Health Organization (WHO) has characterized
depression as a serious public health issue (World Health
Organization, 2012). Current annual health care expendi-

8. tures for the treatment of depression in the US alone
exceed $22 billion (Soni, 2012). In addition, the annual
per capita health care costs for older Americans with
depression exceed $20,000, which is more than double the
cost of those who do not (Un€utzer et al., 2009). Untreated
depression typically becomes chronic in nature (Chap-
man, Perry, & Strine, 2005; Fiske, Wetherell, & Gatz,
2009), negatively impacting quality of life (Chapman
et al., 2005; Fiske et al., 2009), the treatment of co-occur-
ring chronic physical health conditions (Centers for Dis-
ease Control and Prevention and National Association of
Chronic Disease Directors, 2009), and potentially decreas-
ing life expectancy by 5–10 years (Chapman et al., 2005).
Depression is recognized as the most common, treatable
chronic mental health condition among older adults (Cen-
ters for Disease Control and Prevention, 2015). Popula-
tion-based prevalence estimates of depression among
Americans aged 50 and older in the general population
are typically reported to range from 1% to 5% (Centers

9. for Disease Control and Prevention, 2015). National Sur-
vey on Drug Use and Health (NSDUH) and Behavioral
Risk Factor Surveillance System (BRFSS) data indicate
prevalences among adults aged 50 and older ranging from
about 6% (Substance Abuse and Mental Health Services
Administration, 2013) to about 8%, respectively (Centers
for Disease Control and Prevention and National Associa-
tion of Chronic Disease Directors, 2009). Clinically sig-
nificant depressive symptomatology among older
community-dwelling adults may be as high as 15% (Fiske
et al., 2009).
Census projections suggest that the number of Ameri-
cans aged 50 and older will grow to more than 130 million
by 2030, and will approach 164 million by 2060 (U.S.
Census Bureau, 2015). Current national estimates suggest
that 2.6–4.9 million of these will self-identify as lesbian,
gay, and bisexual (LGB) (Gates & Newport, 2012). Our
knowledge of the health and well-being of LGB older

10. adults remains a significant shortcoming in health dispar-
ities research (Centers for Disease Control and Preven-
tion, 2011; Fredriksen-Goldsen, Emlet, et al., 2013). Yet,
LGB Americans aged 50 and older have been found to be
a health disparate population, evidencing higher rates of
poor mental health as well as other physical health prob-
lems than heterosexual older adults (Fredriksen-Goldsen,
Kim, Barkan, Muraco, & Hoy-Ellis, 2013; Wallace,
Cochran, Durazo, & Ford, 2011). In large community-
based samples, 29% of LGB older adults (Fredriksen-
Goldsen, Emlet, et al., 2013) and 47% of transgender
older adults (Fredriksen-Goldsen, Cook-Daniels, et al.,
2013) have been found to have clinically significant
depressive symptomatology. While poor mental health
outcomes among lesbian, gay, bisexual, or transgender
*Corresponding author. Email: [email protected]
� 2016 Informa UK Limited, trading as Taylor & Francis Group
Aging & Mental Health, 2016

11. Vol. 20, No. 11, 1119–1130,
http://dx.doi.org/10.1080/13607863.2016.1168362
mailto:[email protected]
http://dx.doi.org/10.1080/13607863.2016.1168362
(LGBT) older adults are being recognized, the underlying
processes tend to be less understood (Institute of Medi-
cine, 2011). A major goal of the Healthy People 2020 ini-
tiative is to improve the health and well-being of LGB
communities, including reducing the incidence of major
depression among LGB adults as a targeted objective
(U.S. Department of Health and Human Services, 2013).
Meeting this objective will require a better understanding
of depression among LGB older adults so that culturally
responsive intervention and prevention efforts can be
developed and implemented.
Depression is not a part of the normative aging pro-
cess. According to the diathesis-stress perspective, depres-
sion due to genetic diathesis is more common among
younger adults; disruptions resulting from significant life

12. events and cumulative social, psychological, and biologi-
cal stressors are more likely to result in depression among
older adults (Blazer & Hybels, 2005; Fiske et al., 2009;
Zuckerman, 1999). General stressors that increase the risk
for depression in older adulthood are common to both
LGB and heterosexual older adults. These include finan-
cial challenges, decreased social interactions, social isola-
tion, bereavement, and other negative life events (Fiske
et al., 2009). Numerous chronic medical conditions have
been linked to depression among older adults (Blazer,
2003; Chapman et al., 2005; Fiske et al., 2009; Yang,
2007). Adults in the general population living with
chronic health conditions, particularly those aged 40–
59 years old have a significantly increased risk for devel-
oping depression (Pratt & Brody, 2008). Just under 80%
of Americans aged 50 and older have at least one chronic
health condition (AARP Public Policy Institute, 2010;
Centers for Disease Control and Prevention, 2013).

13. Chronic health conditions most often associated with
depression include asthma, arthritis, cardiovascular dis-
ease (CVD), diabetes, and obesity (Chapman et al., 2005;
Fiske et al., 2009). Emerging evidence indicates that com-
pared to their heterosexual counterparts, LGB adults aged
50 and older are also at heightened risk for a variety of
chronic physical health conditions, including CVD, obe-
sity, and asthma among sexual minority women (Fredrik-
sen-Goldsen, Kim, et al., 2013), and hypertension and
diabetes among sexual minority men (Wallace et al.,
2011). These conditions are among the most prevalent
associated with increased risk of developing or exacerbat-
ing the course of depressive disorders (Chapman et al.,
2005; Fiske et al., 2009).
LGB older adults also experience additional stressors
unique to their sexual orientation, which stem from living
in a heterosexist society and are theorized to contribute to
their ‘excess’ rates of depression (Centers for Disease

14. Control and Prevention, 2013). Heterosexism can be
described as the collective constellation of societal preju-
dice, attitudes, stereotypes, and beliefs that cast heterosex-
uality as normative and any other form of human sexual
identity, attraction, and/or behavior as abnormal (Herek &
Garnets, 2007). The minority stress model identifies pro-
cesses by which heterosexist-related minority stressors
negatively impact the mental health of LGB people
(Meyer, 2003). Internals of minority stressors, internal-
ized heterosexism and concealment of sexual orientation,
are the most chronic and inescapable (Meyer, 2003) and,
thus, may play a crucial role in heightened risk for depres-
sion among older LGB adults. Internalized heterosexism
refers to early and ongoing socialization processes by
which people internalize society’s prejudicial attitudes,
stereotypes, and beliefs regarding non-heterosexuality.
Consciously and unconsciously, LGB people may apply
such internalized representations to themselves and to

15. other LGB people (Meyer, 2003). Internalized heterosex-
ism has been associated with increased risk for depression
among LGB older adults (Fredriksen-Goldsen, Emlet,
et al., 2013).
Self-concealment of personal information and secrets
of a distressing nature have been consistently linked to
physiological symptoms in the general population (Uysal,
Lin, & Knee, 2010). Concealing one’s non-heterosexual
orientation may provide a degree of short-term protection
by making oneself a less visible target for victimization,
but continued concealment over time is psychologically
stressful (Meyer, 2003), negatively impacting neuroendo-
crine functioning (Meyer, 2003) associated with the
development of chronic health conditions (Cole, Kemeny,
Taylor, & Visscher, 1996). A sample of HIV-negative gay
men in the Natural History of AIDS Psychosocial Study
who concealed their sexual orientation developed cancer
at significantly higher rates relative to gay men who dis-

16. closed their sexual orientation (Cole et al., 1996). Recent
epigenetic research has identified chronic stress as playing
a role in the expression of the ATF3 gene in breast cancer
metastasis (Wolford et al., 2013). Alternately, disclosure
of one’s LGB sexual orientation is posited to counteract
the negative impacts of chronic minority stress by provid-
ing individual and group-level coping resources (Meyer,
2003). Research findings regarding the role of conceal-
ment and disclosure of sexual orientation and risk of
depression among older LGB adults have been mixed.
Data from the Urban Men’s Health Study (UMHS) indi-
cated that disclosure is associated with greater risk for
depression among gay men aged 50–59, but not for those
aged 60 and older (Rawls, 2004). Another study found
that disclosure of sexual orientation among older LGB
adults is associated with lower levels of depression, but
that relationship is indirectly working through internalized
heterosexism (Hoy-Ellis, 2015). Yet, a different study

17. found no relationship between concealment or disclosure
of sexual orientation and depression, when controlling for
demographic characteristics and other risk and protective
factors (Fredriksen-Goldsen, Emlet, et al., 2013).
The significance of the current study is that it exam-
ines the relative roles of the most internal of minority
stressors, internalized heterosexism and concealment or
disclosure of sexual orientation, and chronic health condi-
tions in depression among older LGB adults. It also seeks
to explore if disparities in certain chronic physical health
conditions identified in this population may contribute to
disparities in poor mental health. Specifically, this study
aims to test the following hypothesized relationships:
(1) Disclosure of sexual orientation is directly and
inversely related to internalized heterosexism,
chronic health conditions, and depression.
1120 C. P. Hoy-Ellis and K. I. Fredriksen-Goldsen

18. (2) Disclosure of sexual orientation is inversely and
indirectly associated with chronic health condi-
tions and depression through internalized
heterosexism.
(3) Internalized heterosexism is directly and posi-
tively related to chronic physical health condi-
tions and depression.
(4) Internalized heterosexism is positively and indi-
rectly associated with depression via chronic
physical health conditions.
(5) Chronic physical health conditions have an addi-
tional positive relationship with depression among
LGB older adults, net of disclosure of sexual ori-
entation and internalized heterosexism (see
Figure 1 for model to be tested).
Methods
Sample and procedure
This study is a secondary analysis of data from the

19. National Health, Aging, & Sexuality Study: Caring &
Aging with Pride Over Time (NHAS), the first of its kind
national study to investigate the health and well-being of
LGB older adults as a population distinct from both their
younger LGB peers and older heterosexual adult counter-
parts. The Institute for Multigenerational Health at the
University of Washington, Seattle, partnered with 11
agencies across the US, which provide programming and
services specific to LGB older adults. A survey was devel-
oped and distributed via agency mailing lists from June
through November of 2010. The survey included ques-
tions to assess standard sociodemographic information, as
well as sexual orientation and gender identity. Also
included in the survey were items particularly relevant to
LGB experience, such as disclosure of sexual orientation
or gender identity, and measures of physical and mental
health. Inclusion criteria for the NHAS required that (1)
potential participants be 50 years old or older at the time

20. of the survey distribution and (2) self-identify as LGBT.
Along with standard informed consent and anonymity
protocols, participants were offered an opportunity to
enter a raffle to win one of five $500 gift cards for their
time, winners to be chosen randomly. The University of
Washington Institutional Review Board approved all
study materials, procedures, and safeguards for the protec-
tion of human participants; many partnering agencies con-
ducted their own internal reviews. The final dataset was
comprised of surveys completed by 2560 LGBT adults
aged 50–95 years old. For a fuller description of the
NHAS, see Fredriksen-Goldsen, Kim and associates
(2013).
The sample for the current study (n D 2349) consisted
of 829 self-identified bisexual and lesbian women (35%)
and 1520 bisexual and gay men. Transgender participants
were excluded and studied elsewhere. Sample participants
ranged in age from 50 to 95 years old (M D 66.9; SD D
9.0), most identified as lesbian or gay (95%), and were

21. Figure 1. Structural equation model to be tested.
Note: Model showing direct and indirect relationships between
latent variables concealment and internalized heterosexism; and
observed
variables chronic health conditions and depression.
Aging & Mental Health 1121
predominantly non-Hispanic white (87.0%). Although the
majority (92%) had at least some college education, about
half (52%) reported annual household incomes of
$49,999. See Table 1 for sample sociodemographic
characteristics.
Measures
Covariates income and education were controlled for, as
the robust associations between these variables and
chronic health conditions and depression have been
widely established (Marmot & Wilkinson, 2006; World
Health Organization, 2003). Age was also treated as a
covariate as it has been related to disclosure of sexual ori-
entation and internalized heterosexism (David & Knight,

22. 2008). Annual household income was coded across six
categories: <$20,000; $20,000–$24,999; $25,000–
$34,999; $35,000–$49,999; $50,000–$74,999; and
$75,000 or more. Educational attainment was categorized
as: kindergarten or none; grade 9–11; grade 12 or GED
(General Educational Development Test, a certification
that is equivalent to a high school diploma); college of 1–
3 years; and college of 4 years or more. Age was calcu-
lated from reported year of birth.
A latent variable to assess the degree of disclosure of
the participants’ sexual orientation was constructed from
a modified version of the 12-item Outness Inventory
(Mohr & Fassinger, 2000), which assesses sexual orienta-
tion disclosure in three primary social domains. Partici-
pants indicated the likelihood that family members (e.g.
parent, sibling), community members (e.g. neighbors, faith
community), and a best friend know or have known their
sexual orientation on a 4-point Likert scale (1 D definitely

23. do not know through 4 D definitely do know). Factor anal-
yses indicated that the three indicators (out to friend, fam-
ily, community) loaded well onto a single factor (.63–.91,
p < .001). Internal consistency was acceptable,
Cronbach’s a D .71. Higher scores indicate higher levels
of disclosure of sexual orientation.
A separate latent variable with five indicators was
constructed to capture internalized heterosexism, utilizing
the Homosexual Self-Stigma subscale (Liu, Feng, & Rho-
des, 2009). Participants indicated their level of agreement
with five statements such as ‘I wish I weren’t lesbian, gay,
bisexual, or transgender’ coded on a 4-point Likert scale
(1 D strongly agree through 4 D strongly disagree). Fac-
tor analyses indicated that all five items loaded well onto
a single latent factor (.48–.79, p < .001), with acceptable
internal consistency (Cronbach’s a D .79). Responses
were then reverse-coded so that higher scores indicated
higher levels of internalized heterosexism.
Chronic health conditions were treated as an observed
variable based on participants’ endorsement (‘mark all

24. that apply’) of whether they had ever been told by a physi-
cian that they had any of the following nine chronic health
conditions identified in the literature as being associated
with depression: angina, arthritis, congestive heart fail-
ure, diabetes, heart attack, high cholesterol, hypertension,
osteoporosis, and stroke. A number of conditions were
summed, producing a range of 0–9, with higher numbers
indicating the presence of more chronic health conditions.
Depression was assessed via the Center for Epidemio-
logical Studies Depression Scale 10-item short form
(CESD-10) (Radloff, 1977), which has well-established
validity and reliability in screening for major depression
across populations (Grzywacz, Hovey, Seligman, Arcury,
& Quandt, 2006; Zhang et al., 2012), including among
community-dwelling older adults (Andresen, Malmgren,
Carter, & Patrick, 1994; Boey, 1999; Irwin, Artin, &
Oxman, 1999). Depression was treated as an observed
variable, making for a more parsimonious the model;

25. model fit decreases as the number of variables increases
(Kenny, 2014). The CESD-10 calls for participants to
indicate how many days during the past week (0 D
<1 day, 1 D 1–2 days; 2 D 3–4 days; 3 D 5–7 days) they
had felt or acted in certain ways; for example, ‘I felt
depressed,’ and ‘everything I did was an effort.’ Internal
consistency was good, Cronbach’s a D 0.88. On a range
of 0–30, a score �10 is an indicator of depressive symp-
toms that meet clinically significant levels (Andresen
et al., 1994; Zhang et al., 2012).
Statistical analyses
Structural equation modeling (SEM) using Stata v. 12 was
employed for all analyses. SEM is a confirmatory statisti-
cal technique useful for testing a priori theorized models
(Bollen, 1989). A sample variance–covariance matrix is
computed and compared to an estimated population vari-
ance–covariance matrix; if the difference between the two
matrices is close to zero, the model is considered to be a
good fit to the data (Bollen, 1989). In SEM, the
Table 1. Sample sociodemographic characteristics.

26. Variable (%) (n)
Age M (SD) 66.9 (9.0) 2372
Gender
Women 35.4 840
Men 64.6 1531
Sexual orientation
Lesbian/gay 94.6 2217
Bisexual 5.4 124
Race/ethnicity
Hispanic/non-Hispanic, non-white 13.0 343
Non-Hispanic white 87.0 2198
Education
Grade 1–8 0.2 4
Grade 9–11 0.8 19
Grade 12 or GED 6.7 158
College 1–3 years 18.2 427
College 4 years or more 74.2 1744
Annual household income

27. <$20,000 18.2 399
$20,000–$24,999 8.3 186
$25,000–$34,999 11.7 269
$35,000–$49,999 14.3 329
$50,000–$74,999 17.0 396
$75,000 or more 30.6 721
1122 C. P. Hoy-Ellis and K. I. Fredriksen-Goldsen
measurement model provides information as to how well
indicators load onto latent variables (i.e. confirmatory fac-
tor analysis); the structural model provides information
on the relationships between variables. SEM has some
advantages over more traditional multiple regression tech-
niques. Standard regression models assume ‘perfect meas-
urement’ which produces biased estimates (Baron &
Kenny, 1986); SEM accounts for measurement error (Bol-
len, 1989), and is more sensitive to detecting suppressor
effects (Cheung & Lau, 2008) and mediation effects

28. (Iacobucci, Saldhana, & Deng, 2007). Total effects can be
decomposed into their direct and indirect components,
allowing inferences about mediation effects to be made
(Duncan, 1975). Because equations are estimated simulta-
neously, standard errors are smaller and more consistent
(Iacobucci et al., 2007).
In this study, the Maximum Likelihood estimator with
pairwise deletion was used for model-testing. The data
were not normally distributed, therefore, bootstrapping,
resampling with replacement (500 replications), was
employed to derive a sampling distribution for more pre-
cise standard errors and accurate confidence intervals (CI)
(Cheung & Lau, 2008). A Variance Inflation Factor (VIF)
was computed to assess for possible issues of multicolli-
nearity, which preliminary analyses indicated was not an
issue; VIF D 1.07, well below the acceptable upper bound
of 10 (StataCorp, 2011). Hooper, Coughlan, and Mullen
(2008) recommend assessing an array of post-estimation
goodness-of-fit (GOF) statistics to examine model fit. The

29. model x
2
is typically reported, yet, with very large sample
sizes (i.e. �200); this statistic will almost always be sig-
nificant (Matsueda, 2012), requiring rejection of the null
hypothesis. However, a non-significant difference
between the sample and estimated population variance–
covariance matrices is indicative of a good model fit. Of
other test statistics endorsed by Hooper et al. (2008), the
Comparative Fit Index (CFI) is minimally affected by
sample size, thus, addressing the issue of model x
2
signifi-
cance. It contrasts the null model against the sample
covariance matrix and calculates a statistic that ranges
from 0 to 1; a value >.90 suggests a good model fit.
Among the most revealing of fit statistics, the Root Mean
Square Error of Approximation (RMSEA) identifies the
closeness of fit between the population covariance matrix
and sample parameters; a value <.06 indicates a good fit

30. between the model and the data (Hooper et al., 2008). The
Standardized Root Mean Square Residual (SRMR) is a
measure of the difference between the standardized square
root residuals of the sample and hypothesized population
covariance matrices. While an SRMR < .08 is considered
adequate, a value <.05 suggests a better model fit (Hooper
et al., 2008). In addition, a CI close to zero implies that the
sample and hypothesized population covariance matrices
do not differ significantly.
Results
Overall, 29% of the sample (n D 666) reported clinical
symptoms that met the threshold of major depression,
scoring �10 on the CESD-10 (M D 7.2, SD D 6.2). The
average level of disclosure, 3.5 on a scale of 1–4 (SD D
.6) was relatively high, and the mean level of internalized
heterosexism, 1.5 on a scale of 1–4 (SD D .6) was rela-
tively low. Participants had on average 1.9 chronic health
conditions (SD D 1.4). See Table 2 for sample summary
statistics and distributions of chronic health conditions.
To further assess model fit, a Lagrange Multiplier Test

31. to detect omitted paths and provide estimates of change in
model fit was conducted. Adding omitted paths is method-
ologically sound, provided that such additions are consis-
tent with theory (StataCorp, 2011). Correlated error term
paths were added (not shown), which is theoretically
sound as indicators of observed measures are themselves
typically correlated (see Table 3 for correlation matrix).
The final fitted model is shown in Figure 2. With the
exception of the x
2
-statistic, post-estimation GOF test sta-
tistics separately and collectively suggest a very close fit
of the model to the data (see Table 4).
Factor loadings and path coefficients in Figure 2 are
standardized to facilitate interpretation of relationships
and effect sizes (Preacher & Kelley, 2011). Initial results
initially indicated that disclosure of sexual orientation did
not appear to have a significant association with either
depression (p D .089) or chronic health conditions (p D
.679). However, decomposition of total effects into their

32. direct and indirect components (see Table 5) suggests that
the indirect effect of disclosure is significantly related to
both depression (p < .001) and chronic health conditions
(p D .030). Indirect effects may be significant even though
direct and total effects are not, such as the case when the
indirect effect has an opposite sign, which may indicate
that the mediating variable (i.e. internalized heterosexism)
also acts as a suppressor, strengthening or weakening the
effect of the independent variable on the dependent vari-
able, thereby, obscuring the total effect (Rucker, Preacher,
Tormala, & Petty, 2011). Opposite signs of the indirect
coefficients are seen in Table 5. These relationships are in
line with minority stress theory in that disclosure of sexual
orientation decreases the stressful effects if internalized
heterosexism (Meyer, 2003), which in turn, would attenu-
ate the positive associations between internalized hetero-
sexism with depression and chronic health conditions.
Significant direct positive associations were found

33. between internalized heterosexism and both depression
Table 2. Sample summary statistics and distribution of chronic
health conditions.
Variable Range M (SD) Chronic conditions (%) (n)
Disclose to friend 3.9 (0.6) Angina 3.9 92
Disclose to family 1–4 3.4 (0.8) Arthritis 33.8 802
Disclose to community 3.5 (0.7) Congestive heart
failure
2.7 63
Disclosure overall 3.5 (0.6) Diabetes 13.7 324
Internalized heterosexism 1–4 1.5 (0.6) Heart attack 5.6 132
Chronic health conditions 0–9 1.9 (1.4) High cholesterol 43.3
1027
Depression (CESD) 0–30 7.2 (6.2) Hypertension 45.5 1079
CESD � 10 29.2% n D 666 Osteoporosis 10.2 243
Stroke 3.9 92
Aging & Mental Health 1123
and chronic health conditions, as well as an additional
indirect association with depression via chronic health

34. conditions; chronic health conditions have an additional
positive direct association with depression (see Table 5).
The cumulative direct, indirect, and total effects of con-
cealment of sexual orientation, internalized heterosexism,
and chronic health conditions indicate that these variables
account for just under 76% of the variance in depression.
Discussion
Emerging research suggests that LGB older adults have a
significantly greater risk for depression and several
chronic health conditions (Fredriksen-Goldsen, Kim,
et al., 2013; Valanis et al., 2000; Wallace et al., 2011).
Concealment of sexual orientation (Hoy-Ellis, 2015) and
internalized heterosexism may increase the risk for
Figure 2. Fitted structural equation model.
Note: Showing direct and indirect relationships between latent
variables concealment and internalized heterosexism; and
observed varia-
bles chronic health conditions and depression. Factor loadings
and path coefficients are standardized.
�
p < .05.

35. ��
p < .01.
���
p < .001.
Table 3. Correlations of observed measures.
Disclosure (D) Internalized heterosexism (IH)
Family Friend Community A B C D E Chronic CESD Age
Income Education
D-family 1.00
D-friend .38 1.00
D-community .49 .45 1.00
IH-A ¡.18 ¡.11 ¡.23 1.00
IH-B ¡.11 ¡.06 ¡.09 .39 1.00
IH-C ¡.17 ¡.13 ¡.20 .71 .09 1.00
IH-D ¡.19 ¡.14 ¡.22 .60 .37 .59 1.00
IH-E ¡.13 ¡.08 ¡.14 .38 .26 .41 .53 1.00
Chronic ¡.08 ¡.04 ¡.05 .07 .04 .06 .08 .04 1.00
CESD ¡.04 ¡.06 ¡.05 .18 .09 .14 .20 .11 .18 1.00
Age ¡.31 ¡.12 ¡.16 .11 .02 .06 .11 .06 .22 ¡.02 1.00
Income .13 .10 .14 ¡.10 .02 ¡.05 ¡.13 ¡.07 ¡.17 ¡.31 ¡.17 1.00
Education .07 .10 .10 ¡.04 .04 ¡.01 ¡.07 ¡.05 ¡.12 ¡.16 ¡.07 .36
1.00
1124 C. P. Hoy-Ellis and K. I. Fredriksen-Goldsen
depression (Fredriksen-Goldsen, Emlet, et al., 2013; Hoy-

36. Ellis, 2015) among LGB older adults (Fredriksen-Gold-
sen, Emlet, et al., 2013). The results reported here suggest
that disparities in chronic health conditions documented
among LGB older adults may explain some of the dispar-
ity in their rates of depression, aligning with research in
the general older adult population linking chronic health
conditions with increased risk for depression (Blazer &
Hybels, 2005; Chapman et al., 2005; Fiske et al., 2009).
Findings also provide additional evidence that minority
stressors are cumulative in their effects on mental health
outcomes (Meyer, 2003), and that pathways of risk are
complex and may be obscured (Institute of Medicine,
2011). Disclosure of sexual orientation appears to be
related to lower levels of internalized heterosexism,
thereby, reducing the positive associations between both
internalized heterosexism and chronic health conditions
on depression. Internalized heterosexism and chronic
health conditions may have additional impacts on depres-

37. sion, net of disclosure of sexual orientation, suggesting
that social, psychological, and physical factors be consid-
ered in tandem when examining depression among LGB
older adults.
The finding that higher levels of disclosure of sexual
orientation are inversely related to internalized heterosex-
ism and indirectly with depression mediated by internal-
ized heterosexism is consistent with the minority stress
model. Long-term concealment of a significant aspect of
the self is psychologically costly (Meyer, 2003), which
can be attributed to potential negative consequences of
disclosure, shame, guilt, and distorted thinking that related
to internalized heterosexism (Pachankis, 2007). Through
disclosure of sexual orientation, important individual and
group-level coping processes are activated reducing levels
of internalized heterosexism (Meyer, 2003). When avail-
able, coping resources are deemed to be adequate to meet
perceived threat through secondary appraisals (Lazarus &

38. Folkman, 1984); the stress response and risk for depres-
sion are significantly diminished (Juster, McEwen, &
Lupien, 2010). Consistent with social comparison theory
(Hogg, Terry, & White, 1995) at the individual level, dis-
closure diminishes feelings of shame and guilt (Pachankis,
2007), and through subsequent positive comparisons of
the self with other LGBs, replacing hitherto negative com-
parisons with heterosexuals, distorted cognitions regard-
ing the self are ameliorated (Meyer, 2003).
The indirect relationship between concealment and
chronic health conditions, mediated via internalized het-
erosexism and the additional direct effect of internalized
heterosexism on both chronic health conditions and
depression, is consistent with social stress theory broadly,
and the minority stress framework in particular. Decades
of social stress research have demonstrated that chronic
psychosocial stressors ‘gets under the skin’ to become
embodied and consequently manifest in chronic disease

39. (Ferraro & Shippee, 2009; Krieger, 1999), such as CVD,
diabetes (Juster et al., 2010), hypertension, and asthma
(Katon, 2011), particularly among socially marginalized
groups (Aneshensel, 2009). The internalization of stigma
associated with marginalized social status has been char-
acterized as a chronic stressor in and of itself (Hatzen-
buehler, Phelan, & Link, 2013). The hypothalamic-
pituitary-adrenal (HPA) axis is central to neuroendocrine
processes that are activated in response to stressors (Juster
et al., 2010; McEwen, 1998). Cortisol and adrenaline are
primary hormones released in this response process.
When stressors are acute and relatively sporadic, the
release of these hormones may enhance survival. When
stressors are chronic, repeated over-activation of the
Table 4. Model goodness-of-fit statistics.
Statistical test Statistical value
Model x
2
(df) 143.64 (42)

40. Root Mean Square Error of Approximation
(RMSEA)
0.035
Confidence interval (CI) (90%) [.029, .042]
Comparative Fit Index (CFI) 0.981
Standardized Root Mean Square Residual
(SRMR)
0.023
Coefficient of determination (CD) (model R
2
) 0.757
Table 5. Decomposition of total, direct, and indirect effects.
Depression
b
�
se p > z b
�
se p > z b
�
se p > z
Direct Indirect Total

41. Disclosure .013 .326 .683 ¡.064 .168 <.001 ¡.051 .309 .089
Internalized heterosexism .186 .418 <.001 .009 .050 .022 .195
.424 <.001
Chronic health conditions .143 .103 <.001 (No path) .143 .103
<.001
Internalized heterosexism
Disclosure ¡.354 .048 <.001 (No path) ¡.354 .048 <.001
Chronic health conditions
Disclosure .032 .064 .249 ¡.021 .023 .030 .011 .060 .679
Internalized heterosexism .060 .079 .022 (No path) .060 .079
.022
Note: b
� D Standardized coefficient; se D bootstrapped standard error.
Aging & Mental Health 1125
HPA-axis results in allostatic load (AL) (Juster et al.,
2010; McEwen, 1998). Among other negative physiologi-
cal effects, AL has been linked to metabolic dysfunctions
such as hyperlipidemia and insulin resistance, which are
associated with diabetes, hypertension, and CVD (Juster
et al., 2010; McEwen, 1998). Regions of the brain

42. involved in threat appraisal processes are also negatively
impacted by AL, resulting in decreased perceived coping
resources and increased risk for depression (McEwen,
2006).
Chronic health conditions also have an additional
direct association with depression, net of all other rela-
tionships. Having chronic health conditions increases the
risk for developing depression or exacerbating existent
depression (Chapman et al., 2005; Katon, 2011; Wolko-
witz, Reus, & Mellon, 2011). There is also a direct rela-
tionship between increasing numbers of chronic health
conditions and increased risk of developing or worsening
depression (Chapman et al., 2005). It is, thus, plausible
that the heightened risk of chronic health conditions iden-
tified among LGB older adults (Fredriksen-Goldsen, Kim,
et al., 2013; Wallace et al., 2011) plays an important role
in the disparately high rates of depression documented in
this population. The relationship between chronic health

43. conditions and depression is also consistent with the
broader social stress literature. LGB older adults are mar-
ginalized both by their sexual orientation and their age
(Fredriksen-Goldsen, Hoy-Ellis, Goldsen, Emlet, &
Hooyman, 2014), resulting in social exclusion and lower
social standing. Findings from the Whitehall studies have
advanced our understanding of the relationship between
lower social standing, chronic health conditions, and poor
mental health outcomes by showing that the underlying
mechanism of risk is decreased control over important
aspects of the social environment that accompanies lower
social standing (Marmot et al., 1991; Marmot & Wilkin-
son, 2006). The presence of chronic health can also limit
control over key aspects of one’s life (Blazer, 2003;
Katon, 2011).
Implications
There is a dearth of research that attends to midlife and
older LGB adults as a population distinct from both mid-

44. life and older heterosexual adults, and from younger adult
and adolescent sexual minorities. The little research that
has made such comparisons indicates that there are impor-
tant differences between these respective groups (Fredrik-
sen-Goldsen, Kim, et al., 2013; Kertzner, Meyer, Frost, &
Stirratt, 2009; Wallace et al., 2011). Today’s LGB older
adults are more likely to conceal their sexual orientation
than their younger LGB counterparts (Floyd & Bakeman,
2006). Within-group differences by age are also beginning
to emerge. For example, LGB adults aged 50–64 years old
report higher rates of discrimination and victimization
than their counterparts aged 65 and older, yet, the latter
age group evidences higher levels of internalized hetero-
sexism and is more likely to conceal their sexual orienta-
tion than the former (Fredriksen-Goldsen, Kim, Shiu,
Goldsen, & Emlet, 2014). Fearing discrimination by staff,
and harassment and isolation from other clients, even
LGB older adults who are open about their sexual orienta-

45. tion believe that they will need to conceal their identity in
order to access mainstream aging services – at the very
time when advancing age increases the likelihood of need-
ing such services (National Senior Citizens Law Center,
2011). Yet, these findings suggest that to do so, may place
LGB older adults at increased risk for depression.
This study makes a significant contribution to our
knowledge regarding the health and well-being of older
LGB adults by identifying how minority stress risk factors
and chronic health conditions are associated with each
other and with depression. Identifying that chronic health
conditions play a role in the minority stress process may
enhance our understanding of why rates of depression
remain alarmingly high as LGB individuals get older (Fre-
driksen-Goldsen, Kim, et al., 2013; Wallace et al., 2011),
while rates of depression decline noticeably in the general
population as it ages (Blanchflower & Oswald, 2008;
Blazer, 2003; Yang, 2007). Furthermore, results may also

46. contribute to clarifying the theoretical relationship
between internal minority stressors of concealing LGB
sexual orientation and internalized heterosexism, and
depression. Identifying and understanding the complex
interactions of minority stress processes as they relate to
health will be central to developing culturally sensitive
and effective interventions for LGB older adults living
with depression.
There is evidence that the relationship between
chronic health conditions and depression is recursive
(Chapman et al., 2005; Katon, 2011; Pinquart & Sorenson,
2007). Many chronic health conditions that begin to mani-
fest around the age of 50 may be rooted in chronic stress
that begins in earlier life experience (Kuzawa & Sweet,
2009; Murgatroyd & Spengler, 2011; Seeman, Singer,
Ryff, Dienberg Love, & Levy-Storms, 2002; Wolkowitz
et al., 2011). The corrosive effects of internalized hetero-
sexism that surfaces earlier in life when one begins to

47. realize a non-heterosexual orientation would fall squarely
in the category of ‘chronic stress that begins in earlier life
experience.’ The same array of complex neurobiological
patterns found between chronic social stress and HPA-
axis dysregulation and AL is found in the relationship
between chronic health conditions and depression (Chap-
man et al., 2005; Katon, 2011; Wolkowitz et al., 2011).
Primary and secondary appraisals of threat and available
coping resources are mediated by the brain (Lazarus &
Folkman, 1984; McEwen, 1998). The ongoing dilemma
of whether, when, where, how, and under what circum-
stances one conceals or discloses sexual orientation, cou-
pled with attempting to gauge potential consequences is a
primary appraisal process. If the individual chooses to
continue concealing her or his sexual orientation, then
concealment itself may be an additional chronic stressor
(Meyer, 2003). On the other hand, disclosure may over
time provide additional coping resources, reduce levels of

48. internalized heterosexism, and buffer the impact of stress
processes on health. Still, it is possible that those with
depression are more likely to report having been diag-
nosed with chronic health conditions. Longitudinal
1126 C. P. Hoy-Ellis and K. I. Fredriksen-Goldsen
research will be needed to clarify this relationship among
LGB older adults.
This study has also practice implications for address-
ing depression related to sexual orientation among LGB
older adults. Individual appraisals of stressors are central
to social stress processes (Pearlin, Mullan, Semple, &
Skaff, 1990). Subjective appraisals of stressors are more
strongly related to poor health outcomes, including
depression (Mittelman, Roth, Haley, & Zarit, 2004) than
objective stressors (Zarit, Todd, & Zarit, 1986). Accurate
assessment is foundational to effective treatment of
depression among older adults (Zarit & Zarit, 2007).

49. Therapeutic interventions to address the damaging effects
of internalized heterosexism have typically focused on
supporting the process of disclosure (Herek & Garnets,
2007). While such an approach can positively influence
the stress appraisal process, it also runs the risk of blaming
the individual for their poor mental health (Meyer, 2003).
On the other hand, if the social environment is less threat-
ening, it is likely to be appraised as less threatening,
which would benefit LGB older adults with depression
who do not have access to LGB-affirmative therapy.
Effectively addressing depression among LGB older
adults that is related to factors associated with sexual ori-
entation goes beyond intervening with current depression;
it also requires prevention efforts. More than two decades
ago, Albee and Ryan-Finn (1993) proposed that the occur-
rence of mental distress stemming from societal oppres-
sion can be described as a function of elements in the
social environment that promote marginalization divided

50. by the capacity of individuals and groups to resist margin-
alization. Taking such a social justice approach to primary
prevention requires empowering LGB older adults to
develop and strengthen their capacity to resist societal het-
erosexism, and that researchers identify and work toward
dismantling heterosexist social structures and institutions
(Kenny & Hage, 2009; Matthews & Adams, 2009). Such
an approach would serve to ameliorate existent depression
among today’s LGB older adults, and contribute to pre-
venting the development of depression among the next
generation of LGB older adults.
Limitations
In addition to its cross-sectional design, this study has
other limitations. Surveys were distributed via agency
mailing lists; participants who responded may differ in
important ways from those who did not. For example,
LGB older adults with higher levels of internalized het-
erosexism may be less likely to participate in research.

51. Similarly, LGB older adults who are not connected with
these service agencies may differ in significant ways from
those who are, for example, differing levels of conceal-
ment and disclosure. The ways in which individuals came
to be on agency mailing lists may also be an issue, as the
majority of respondents in this sample (70.6%) were not
utilizing services at the time that surveys were distributed.
While there is representation across the country, the find-
ings reported here cannot be generalized. Most partici-
pants were concentrated on the West Coast, Eastern
Seaboard, and parts of the Central US in major metropoli-
tan areas. Urban-dwelling LGB older adults likely have
experiences that vary from their rural-dwelling counter-
parts. These limitations may have skewed findings. It is
possible that LGB older adults who are connected with
agencies may differ on both mental and physical health
measures, which if true, likely biases these results.
The psychometric properties of the CESD-10 are well

52. established; measures to assess internalized heterosexism
and concealment/disclosure are less so. The Outness
Inventory (Mohr & Fassinger, 2000) requires subjective
interpretations of other likely perceptions, rather than
whether participants have actively or passively disclosed
or concealed their sexual orientation. The adapted version
of the Homosexuality Stigma Scale (Liu et al., 2009) may
not differentiate well between current and previous levels
of internalized heterosexism. For example, ‘I have tried
not to be LGB’ can refer to previous decades or current
experience.
Nonetheless, this study has valuable strengths. It is
one of the few to specifically examine LGB older adults
as a distinct population, and to apply the minority stress
framework to this population. In addition to providing
support for the minority stress model in general, it also
suggests that internal minority stressors may play a role
in physical as well as mental health outcomes (e.g.

53. depression), and that it is important to attend to both.
Through the use of SEM, this study provides further
evidence that may help to clarify the relationships
between disclosure of sexual orientation, internalized
heterosexism, chronic health conditions, and depression,
particularly the role of internalized heterosexism as
mediator suppressor of disclosure in both physical and
mental health.
Conclusion
We must begin to think in terms of health equity and
move toward targeting interventions upstream at commu-
nity and policy levels. Health equity means that every per-
son, regardless of social characteristics (including sexual
orientation), has a right to the best possible health, which
necessitates that any barriers to health that marginalized
groups experience must be addressed (Braveman & Grus-
kin, 2003). Health disparities are the gauge by which
progress toward health equity can be assessed; for LGB

54. older adults to attain mental health equity in the form of
resolving disparately high rates of depression, we must
attend to the unique barriers that they experience (Fredrik-
sen-Goldsen et al., 2014). Both the perceived and still all
too often real need to conceal an LGB identity – it is still
legal to discriminate based on sexual orientation in the
majority of states (Human Rights Campaign, 2015) – and
internalized heterosexism are barriers to LGB older
adults’ mental health equity. Recognizing that these bar-
riers are ultimately rooted in societal heterosexism
requires that we must also calibrate interventions at com-
munity and policy levels to address macro-level hetero-
sexism that fosters internalized heterosexism and the
perceived need to conceal one’s sexual orientation, which
Aging & Mental Health 1127
eventually manifests downstream in disparately high rates
depression.

55. Acknowledgments
Some research reported in this publication was supported in part
by grants from the National Institute on Aging of the National
Institutes of Health under Award Numbers R01AG026526 and
2R01AG026526-03A1 (Fredriksen-Goldsen, PI). The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health,
National Institute of Aging, the University of Utah, or the Uni-
versity of Washington.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
National Institute on Aging of the National Institutes of
Health [award number R01AG026526], [award number
2R01AG026526-03A1].
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AbstractIntroductionMethodsSample and

71. procedureMeasuresStatistical
analysesResultsDiscussionImplicationsLimitationsConclusionAc
knowledgmentsFundingReferences
Social Integration, Social Support and Mortality in the US
National Health
Interview Survey
STEVEN D. BARGER, PHD
Background: Social relationship quantity and quality are
associated with mortality, but it is unclear whether each
relationship
dimension is equally important for longevity and whether these
associations are sensitive to baseline health status. Methods:
This
study examined the individual and joint associations of
relationship quantity (measured using a social integration score)
and quality
(measured by perceived social support) with mortality in a
representative US sample (n = 30,574). The study also evaluated
whether
these associations were consistent across individuals with and
without diagnosed chronic illness and whether they were
independent of
socioeconomic status (SES; education, income, employment,
and wealth). Baseline data were collected in 2001 and were
linked to vital
status records 5 years later (1836 deaths). Results: Both social
integration and social support were individually related to
mortality
(hazard ratios [HRs] = 0.83 [95% confidence interval {CI} =
0.80Y0.85] and HR = 0.94 [95% CI = 0.89Y0.98], respectively).
However,
in multivariate models including demographic and SES

72. variables, social integration (HR = 0.86, 95% CI = 0.83Y0.89)
but not social
support (HR = 1.03, 95% CI = 0.98Y1.08) was associated with
mortality. The social integration association was linear and
consistent
across baseline health status and men and women. Conclusions:
Social integration but not social support was independently
asso-
ciated with mortality in the US sample. This association was
consistent across baseline health status and not accounted for by
SES.
Key words: mortality determinants, population, social networks,
social support, socioeconomic factors, NHIS.
SES = socioeconomic status; NHIS = National Health Interview
Survey; HR = hazard ratio.
INTRODUCTION
Having and maintaining social relationships are fundamental
human motives (1). Higher-quality relationships and more
frequent social contacts are associated with better health. Re-
lationship quality, broadly labeled functional social relation-
ships, reflects the social and emotional resources that people
have or perceive to have available to them (2). Relationship
quantity, or structural social relationships, reflects participation
in a broad range of social relationships (3).
A meta-analytic review of 148 studies reported that both
functional and structural relationships were inversely associ-
ated with mortality, with effect sizes comparable with health
risks such as smoking (4). Meta-analysis is considered a high-
quality research design (5), and this evidence has been cited in
support of the claim that social relationships, particularly
functional relationships, are important for health (6). However,
there are theoretical and empirical reasons to reexamine

73. whether functional and structural dimensions are equally im-
portant for mortality. For example, some theoretical models
assert that the physical health benefits of structural social re-
lationships are a consequence of social participation itself, not
the supportive functions that social relationships may provide
(7). Other theories exclude supportive functions altogether (8),
instead emphasizing the importance of structural social re-
lationships (e.g., social contact frequency) for health. Thus,
several perspectives suggest that functional relationships may
From the Department of Psychology, Northern Arizona
University, Flagstaff,
Arizona.
Address correspondence and reprint requests to Steven D.
Barger, PhD,
Department of Psychology, Northern Arizona University, PO
Box 15106,
Flagstaff, AZ 86011. E-mail: [email protected]
Supplemental digital content is available for this article. Direct
URL citations
appear in the printed text and are provided in the HTML and
PDF versions of
this article on the journal’s Web site
(www.psychosomaticmedicine.org).
Received for publication July 26, 2012; revision received
January 25, 2013.
DOI: 10.1097/PSY.0b013e318292ad99
not represent the social relationship dimension most relevant to
mortality.
These theoretical assertions can be evaluated by concurrently
comparing these social relationship dimensions in studies that
included both functional and structural relationships. Such

74. studies show a consistent association for structural relation-
ships, whereas the association seems to be sample size depen-
dent for functional relationships. For example, smaller studies
(averaging G60 mortality events) find that both structural and
functional relationships are inversely associated with mortality
(9,10), whereas larger studies (averaging 9700 events) show no
association with functional relationships when structural social
relationship measures are included (11Y14). This inverse asso-
ciation between effect size and study size for functional re-
lationships signals a statistical artifact, that is, inflated effect
estimates caused by small sample sizes (15Y18).
Alternatively, the association of functional relationships
with mortality could be dependent on initial health status, in
that the association occurs only among patient groups or those
who have experienced a serious medical event.1 Patient sam-
ples comprise most studies (18/24) that include only functional
relationship measures (4) and thus can more directly address
whether the apparent survival benefit is restricted to initially
unhealthy samples.
These studies also are consistent with the statistical artifact
hypothesis (e.g., an inverse association between effect size
and sample size) rather than the hypothesis that these associ-
ations are limited to unhealthy samples. Among the 24 studies
in the meta-analysis, 14 found no association of functional
relationships with mortality. For the remaining 10 studies (9
with patient samples, the 10th was an elderly sample averaging
85 years old), the largest 2 (with 9250 events) (19,20) reported
the smallest effects, consistent with the statistical artifact ex-
planation (15,17,21). Moreover, age adjustment eliminated the
association in one study (19), and the other study (20) was
ambiguous because structural social relationship content was
1
The author is grateful to an anonymous reviewer for making this

75. suggestion.
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SOCIAL RELATIONSHIPS AND MORTALITY
included in the functional support measure (e.g., ‘‘I regularly
meet or talk with members of my family or friends’’) (22).
The strong inverse association between effect size and sample
size in these 10 studies (Spearman r = j0.77, p = .009) is
consistent with the statistical artifact interpretation (16,23).
The remaining seven studies also examined initially un-
healthy samples, but effect estimates in those studies are likely
to be biased because of model overfitting (the eighth (24) in-
cluded SES as part of the social relationship assessment and is
not considered further). Overfit regression models have an in-
sufficient number of events relative to the number of covariates
(25). In mortality studies, the limiting sample size is determined
by the number of events rather than by the total number of

76. participants (25,26), and a ratio of 10 to 15 events per predictor
is the minimum necessary to produce unbiased estimates (27).
For five of these seven studies (averaging G60 events), the
event
per predictor ratio was 4 or less (28Y32), indicating substantial
unreliability in the estimates (27). In the remaining two studies
(averaging 174 events), the ratio was less than 15 (33,34). Es-
timates derived from a small event to predictor ratio are
unlikely
to replicate (18,25), an expectation confirmed by the 60% of
studies in the meta-analysis detecting no association between
functional social relationships and mortality. In sum, these sta-
tistical artifacts undermine confidence in the putative associa-
tion of functional relationships with mortality, and these
artifacts persist when considering baseline health status. Al-
though meta-analytic summaries cannot overcome these limi-
tations (15,16,23), large, preferably representative samples
should provide stable and less biased effect estimates (15Y18).
The present study evaluated the association of functional
and structural social relationships with 5-year mortality in a
nationally representative US sample. This sample has a large
number of participants with (95000) and without (925,000)
diagnosed illness, permitting comparison of these social rela-
tionship dimensions across baseline health status. Multivariate
evaluation of other important mortality determinants, such as
socioeconomic status (SES), is facilitated by the large number
of mortality events (91800). SES is particularly important
because it is inversely associated with mortality (35) and
positively associated with social relationships (36,37). SES
was assessed using education and a number of indicators of
material resources (income, wealth [home ownership], and
employment status) (38). Wealth and employment status
measures are rarely included in this literature, but both are
associated with mortality (39,40) and employment status is
particularly relevant because employment provides both eco-

77. nomic and social interaction opportunities. The primary re-
search questions were as follows: (1) do functional and
structural social relationships predict mortality individually
and/
or independently? and (2) are these associations modified by
initial health status or SES? Functional and structural relation-
ships were measured by perceived social support and social in-
tegration, respectively. This study also evaluated whether the
form of the social relationshipYmortality association is linear or
threshold (41) in addition to whether the association is
consistent
for men and women (11,12).
METHODS
Data Source
The National Health Interview Survey (NHIS) is an annual, in-
person cross-
sectional interview of US households. It is the primary source
of health infor-
mation for the noninstitutionalized US population (42).
Analyses are based
on NHIS sample adult participants (n = 33,326; response rate,
73.8%; aged
18Y85+ years) interviewed in 2001 who were eligible for
mortality follow-up in
2006 (n = 31,358; see below). All participants provided
informed consent and
completed the interview in their residence. This study was
exempt from human
subjects review because it involved secondary analysis of
publicly available data
lacking identifying information.
Mortality
The NHIS submitted survey records to the National Death Index

78. for
matching and subsequent vital status ascertainment (43). This
procedure cor-
rectly matches 98.5% of those eligible for mortality follow-up
(44). In 2001,
94% (n = 31,358) of sample adult participants were eligible for
mortality
follow-up. The remaining 6% did not have the minimal
identification data
requirements for reliable matching and thus were ineligible for
vital status
ascertainment (43). New sample weights were created for the
eligible subsample
to represent the noninstitutionalized US population. Death was
coded by year
and quarter and included vital status follow-up through
December 31, 2006.
During the follow-up, 1937 people died.
Social Relationship Assessments
Social support, reflecting the social resources that people
perceive to be
available or are actually provided to them (2), represented the
functional social
relationship dimension. Social support was assessed with the
question ‘‘How
often do you get the social and emotional support you
needValways, usually,
sometimes, rarely, or never?’’ Participants with missing social
support re-
sponses (G2%; n = 534) were excluded.
Social integration, which reflects participation in a broad range
of social

79. relationships (3), represented structural social relationships.
Eight binary
questions, scored 0 being no and 1 being yes, were summed to
create an overall
social integration score. Four questions assessed recent contacts
with friends or
relatives, either over the telephone or in person, excluding
persons living with
the respondent. Three other questions assessed attending a
group social activity,
a religious service, or going out to eat. All seven questions
referred to activity in
the past 2 weeks. The final social integration item was marital
status, defined as
whether respondents were married/cohabiting or not. Although
marital status by
itself is associated with mortality (12,45), it was included in the
social inte-
gration score to parallel prior work showing an inverse
association between
social integration and mortality (40,46,47).
Owing to low frequencies in the zero and one social integration
categories,
these two categories were combined. Thus, social integration
scores could range
from 0/1 to 8. Participants received a social integration score if
they had six or
more valid values on the eight itemsVotherwise, they were
excluded (n = 263).
Missing social support and social integration values reduced the
number of
deaths to 1849.
SES and Demographic Variables
Indicator variables were used to code years of education (less

80. than high school,
high school diploma or equivalent, some college, college
graduate or higher),
household income in 2001 (US$ 0Y$24,999, $20,000Y$34,999,
$35,000Y
$64,999, 9$65,000), and employment (working, retired, out of
work, or never
worked). Wealth was indicated by home ownership (own versus
renting or some
other arrangement). All SES variables were retained in models
regardless of sta-
tistical significance. Demographic variables included age, sex,
and race/ethnicity
(non-Hispanic white, non-Hispanic black, Hispanic, other non-
Hispanic).
Household income had a large number of missing values (21%).
A large
proportion of missing predictors reduce the effective sample
size and may result
in biased and/or inefficient estimates (48,49). To overcome
these potential
limitations, the author used five multiply imputed family
income values pro-
vided by the data producer (50) for SES analyses. These
imputations accom-
modate the complex survey design, add stochastic error
variability to estimates,
and incorporate specialized, nonpublic survey information in
the imputation
Psychosomatic Medicine 75:510Y517 (2013)
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81. 511
S. D. BARGER
procedure (e.g., income mean and standard deviation within
small household TABLE 1. Baseline Demographic, Economic,
and Social Characteristics
area sampling units) (50). Imputed income restored the effective
sample size for of 2001 US National Health Interview Survey
Participants With 5-year
fully adjusted regression models to 30,574 (97.5% of those
eligible for mor-
tality follow-up, 94.8% [n = 1836] of those with ascertained
vital status).
Statistical Analysis
Survival time was defined as time since birth. This time scale is
preferable to
one based on follow-up time (i.e., time from the baseline survey
to mortality
or censoring) because it provides less biased regression
coefficients (51) and
is preferred when age confounding is a concern (52). Analyses
were stratified
by 5-year birth intervals to control for cohort effects (53), and
baseline age
was included as a covariate. In Step 1, social support and social
integration were
entered individually into Cox regression models predicting
survival. In Step 2,
both social relationship variables were entered together. Models

82. were adjusted for
demographics in Step 3 and then SES in Step 4. To address
whether the social
relationshipYmortality association is dependent on initial health
status, analyses
were repeated for healthy and unhealthy subgroups (participants
who reported at
least one chronic disease at baseline). Ancillary analyses of
social support only
were also conducted across the healthy and unhealthy groups.
All analyses in-
corporated the complex survey design (strata, clusters, and
weights). Statistical
tests were two tailed, were considered statistically significant if
p e .05, and were
conducted with Stata 11.2 (Stata Corp., College Station, TX).
Model adequacy was evaluated statistically and graphically.
Nonlinear
(squared) predictors were evaluated and discarded because they
did not sig-
nificantly improve prediction. The proportional hazards
assumption (incorpo-
rating clustering and weighting but not strata) for the full model
was satisfied
( p = .50), and graphical inspection of social relationship
residuals confirmed
slopes at or very near zero. Social support and social integration
were modestly
correlated (r = 0.25, p G .001) and were of similar magnitude
to values reported
previously (4). High tolerance values (the reciprocal of the
variance inflation
factor) for social integration (0.85) and social support (0.92)
denote the large
amount of unique variance in mortality explained by these

83. measures relative to all
other predictors in multivariate models. Regression coefficients
and statistical
conclusions were similar to Cox models when analyzing
mortality using a person/
time metric with complementary log-log regression (data not
shown).
The primary outcome was all-cause mortality. To address the
possibility that
poor health status increases both social isolation and early
mortality, sensitivity
analyses were conducted, (1) excluding participants who died
within 1 year after
the interview and (2) including only participants free of
reported disease at
baseline (i.e., stroke, myocardial infarction, other coronary
heart disease, or
cancer, excluding nonmelanoma skin cancer). Additional
analyses were re-
stricted to participants of working age (G65 years).
Both social relationship variables met an interval assumption,
and thus, each
was used as single variables in the regressions (54). However,
to illustrate the
form of the association, hazard ratios (HRs) are presented using
indicator
variables for both social support and social integration.
RESULTS
Participant characteristics are presented in Table 1. Unad-
justed death rates per 10,000 person-years by social support and
social integration are presented in Table 2, with rates for educa-
tion and income provided for comparison. Social support, social

84. integration, and SES were each inversely associated with mor-
tality. As expected (36,37), social relationship resources were
greater at higher levels of each SES marker (see Table, Supple-
mental Digital Content 1, http://links.lww.com/PSYMED/A70).
When analyzed individually, social support and social in-
tegration were inversely associated with mortality. When both
social relationship variables were entered together, social inte-
gration but not social support was inversely associated with
mortality risk. These findings were unaffected by adjustment for
age at study entry (dummy categories in addition to
stratification
by birth cohort), sex, and race/ethnicity and by additional ad-
Vital Status Ascertainment (n = 31,358)
Participant Characteristic M (SD) No. Weighteda %
Age, y 46.3 (17.8)
18Y24 3311 13.2
25Y34 6131 18.2
35Y44 6641 21.8
45Y54 5622 18.8
55Y64 3849 11.9
Q65 5804 16.1
Sex
Women 17,694 52.0
Men 13,664 48.0
Race/Ethnicity
Hispanic 5266 10.8
Non-Hispanic white 20,662 73.6
Non-Hispanic black 4324 11.3
Other non-Hispanic 1106 4.3

85. Educational level
Less than high school 6411 17.6
High school 8905 29.3
Some college 8903 29.1
College graduate or higher 6942 23.4
Missing 197 0.6
Annual household income
$0Y$19,999 6712 14.9
$20,000Y$34,999 5259 15.0
$35,000Y$64,999 6795 23.3
Q$65,000 6019 25.2
Missing 6573 21.6
Employment status
Employed 20,094 66.3
Retired 5054 14.4
Not currently working 4717 14.9
Has never worked 1453 4.1
Unknown 40 0.1
Home tenure
Own home 19,502 70.2
Rent/Other arrangement 11,784 29.6
Missing 72 0.2
Social support
Never 861 2.4
Rarely 1114 3.0
Sometimes 4214 12.1
Usually 10,544 33.9
Always 14,091 46.9
Missing 534 1.6
Social integration score
0/1 589 1.6

86. 2 841 2.3
3 1581 4.5
4 2912 8.2
5 5066 15.0
6 7571 23.9
7 7993 26.2
8 4542 17.6
Missing 9 2 items 263 0.8
SD = standard deviation.
a Percentages are weighted to represent the noninstitutionalized
US population.
Psychosomatic Medicine 75:510Y517 (2013)
Copyright © 2013 by the American Psychosomatic Society.
Unauthorized reproduction of this article is prohibited.
512
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SOCIAL RELATIONSHIPS AND MORTALITY
TABLE 2. Crude Mortality Rates (per 10,000) by Social
Support, Social
Integration, Education, and Income in the 2001 US National
Health
Interview Survey
Rate 95% CI

87. Social support
Never 3.57 2.80Y4.63
Rarely 3.04 2.41Y3.90
Sometimes 2.83 2.50Y3.23
Usually 2.29 2.09Y2.51
Always 2.67 2.49Y2.88
Social integration score
0/1 7.39 5.99Y9.23
2 6.35 5.30Y7.68
3 5.12 4.44Y5.95
4 4.79 4.28Y5.39
5 3.28 2.95Y3.66
6 2.18 1.95Y2.45
7 1.67 1.48Y1.90
8 1.32 1.10Y1.59
Years of education
Less than high school 5.17 4.80Y5.58
High school 2.59 2.37Y2.84