Anxiety about aging, resilience and health Status among Chinese older adults: Findings from Honolulu and Wuhan

Journal Pre-proof Anxiety about Aging, Resilience and Health Status among Chinese Older Adults: Findings from Honolulu and Wuhan Keqing Zhang, Wei Zhang, Bei Wu, Sizhe Liu

PII:

S0167-4943(20)30009-1

DOI:

https://doi.org/10.1016/j.archger.2020.104015

Reference:

AGG 104015

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Archives of Gerontology and Geriatrics

Received Date:

12 October 2019

Revised Date:

15 January 2020

Accepted Date:

21 January 2020

Please cite this article as: Zhang K, Zhang W, Wu B, Liu S, Anxiety about Aging, Resilience and Health Status among Chinese Older Adults: Findings from Honolulu and Wuhan, Archives of Gerontology and Geriatrics (2020), doi: https://doi.org/10.1016/j.archger.2020.104015

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Anxiety about Aging, Resilience and Health Status among Chinese Older Adults: Findings from Honolulu and Wuhan

Keqing Zhang1, Wei Zhang2*, Bei Wu3,4 and Sizhe Liu5

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Department of Sociology, University of Hawaiʻi at Mānoa, Honolulu, USA 96822

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Email: [email protected] Department of Sociology, University of Hawaiʻi at Mānoa, Honolulu, USA 96822 Email: [email protected]

Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York

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University, New York, USA

NYU Aging Incubator, New York University, New York, USA

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Email: [email protected]

Department of Economic Sociology, Shanghai University of Finance and Economics,

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Shanghai, China 200433 Email: [email protected]

Corresponding author.

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Address: Saunders Hall 247D, 2424 Maile Way, Honolulu, HI 96822

Highlights:

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The negative influences that anxiety about aging has brought about to individual health for older adults have been taken into consideration. Individual resilience is not only related to individual health directly, but also can be considered as the moderator to buffer the negative health consequences of anxiety about aging. 1

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A comparison of Chinese older adults living in United States and China is carried out to investigate the possible cultural differences in the focal relationships.

Abstract A growing body of literature found that anxiety about aging is related to health and well-being of older adults. However, very few studies have been conducted on Chinese older adults residing in different countries and examined the role of resilience. Using the Pearlin’s

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Stress Process Model, this study aims to fill in this gap by examining the relationship between anxiety about aging as the stressor and health status among Chinese older adults living in Honolulu, the United States (N=292) and Wuhan, China (N=532). The survey data

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were collected through June 2017 to September 2018, using snowball and convenience sampling strategy. The moderating role of resilience on the focal relationship is also explored.

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Results showed that for both samples, the negative relationship between anxiety about aging and self-rated health was significantly moderated by resilience (18% and 13%, respectively),

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implying the stress-buffering role of resilience. Although both mean levels of resilience and anxiety about aging were lower for the Honolulu sample, the moderating effect appeared to

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be stronger, implying that older adults in the Honolulu sample might rely more on psychological resources such as resilience in coping with stressors, compared with their

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counterparts in Wuhan. However, the moderating effect of resilience did not work for the association between anxiety about aging and number of chronic conditions for both samples.

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Our findings suggest that future research needs to take into account both social and psychological resources when examining anxiety about aging and health status among Chinese older adults residing in different cultural contexts.

Keywords: anxiety about aging, resilience, self-rated health; chronic conditions; cultural comparison 2

1. Introduction Increase of life expectancy is taking place globally. According to Global Health Observatory (GHO), from 2000 to 2016, the average life expectancy increased from 66.5 to 72 years among world population, and in China, the number increased from 71.40 to 76.25 years (2017). The increase of life expectancy is not only a blessing, but also a challenge to older adults. Older adults experiencing various health problems associated with aging such as decreasing mobility, chronic conditions and mental disorder may not always regard aging

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positively and may suffer from aging-related anxiety (Lenze & Wetherell, 2011). Therefore, among the numerous factors that influence how much longer people can live and how well they live, anxiety about aging, usually referred to as concern about adverse physical, mental

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and personal losses during the aging process (Lasher & Faukllender, 1993), has become particular prominent, and such factor has started to attract increasing scholarly attention

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(Andreescu & Varon 2015; Flint, 2005; Pinquart & Duberstein, 2007).

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Different from common anxiety, which is more generic and focuses more on current issues, anxiety about aging is more about future and aging-specific concerns (Lynch, 2000). It is found that anxiety about aging is associated with decreased well-being (De Beurs et al.,

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1999; Lynch, 2000), increased disability (Richardson et al., 2011), depression (Gellis, Kim, & McCracken, 2014), and cognitive impairment (Willson, Begeny, & Boyle 2011). However,

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among the many studies that reported the association of health with anxiety about aging

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(Byers, Yaffe, Covinsky, Friedma, & Bruce, 2010; Goncalves, Pachana, & Byrne, 2011; Potvin, Forget, Grenier, Preville, & Hudon, 2011), few have considered the extent to which psychosocial resources might protect individuals from the negative health consequences brought by anxiety about aging. Positive psychosocial resources, such as self-confidence, sense of purpose, and hardiness, are often used by individuals to fight against anxiety symptoms, and an individual

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utilizing such resources is identified as being “resilient” (Smith, Langa, Kabeto, & Ubel, 2005; Yi, Vitaliano, Smith, Yi, & Weinger, 2008). As a psychosocial resource, resilience is commonly regarded as positive adaptations when faced with threats or challenges (Ahern, Kiel, Sole, & Byers, 2006; Masten, 2014), and resilience is also found to be significantly associated with health and well-being outcomes of older adults, including self-rated health (Montross et al., 2006), cognitive function (Mancini & Bonanno, 2006; Shen & Zeng, 2010), improved lifestyle behaviors (Gooding, Hurst, Johnson, & Tarrier, 2012), as well as

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psychological and subjective well-being (Zhang, Liu, Zhang, & Wu, 2019). Resilient individuals can utilize and develop resources and skills to facilitate positive adaptations as well as to cope with stress (Tugade & Fredrickson, 2004). This prompts us to wonder whether

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levels of resilience may have the potential to act as a stress buffer to impact the relationship between anxiety about aging and health as a coping resource.

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This study also intends to explore cultural differences. The Chinese older adults

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investigated in this study were recruited from two cultural backgrounds: Honolulu, United States and Wuhan, China. The reason why we conducted this comparison study is that cultural background is often regarded as an important factor in the aging process, as the

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experience of living in different environment and being exposed to different cultures would affect various aspects of older adults, including perceptions of aging, subjective experience of

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aging, and different lifestyles.

For instance, in cultures where collectivism is more valued,

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social views about aging tend to be more positive (Lockenhoff et al., 2009; O’Brien et al., 2017). As Asian cultures are more interdependent and collectivism-oriented, there might be more friendly views and attitudes toward aging process and older population (Schwartz, 2006). Older adults living in China tend to be immersed in Chinese environment and culture and experienced limited exposure to the U.S. culture, whereas their counterparts in the United States are likely to situate themselves in mixed cultures—retaining the traditional Chinese

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culture as well as being acculturated into the U.S. culture (Zhang, Lacanienta, Liu, & Wu, 2018). Moreover, immigrant status of older adults in the U.S. might exert some influence on their health conditions, for example possible language barriers or separation from family would lead to negative health consequences (Gierveld, Van der Pas, & Keating, 2015, Lewis, 2009). It would be interesting and meaningful to examine the similarities and differences in our focal relationships among Chinese older adults residing in different cultural contexts. Taken together, utilizing the Stress Process Model developed by Pearlin and colleagues

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(1981), this study aims to investigate the association between anxiety about aging as the stressor and health status among Chinese older adults as an outcome, as well as how resilience as a stress buffer moderates the relationship between the two under different

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cultural backgrounds.

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2.1 Anxiety about aging and health

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2. Theoretical and empirical background

This study uses the Stress Process Model as it incorporates factors that influence the ways in which stressful experiences are translated into health outcomes (Pearlin, Menaghan,

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Lieberman, & Mullan, 1981). Combinations of high stress exposure and low levels of protective factors will result in lower levels of health (Figure 1). The Stress process model

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has been used in health-related studies, especially among older adults (Aneshensel & Avison

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2015; Judge, Heather, & Whitlatch, 2010). A series of empirical studies have produced compelling evidence to illustrate how care-related stressors might create a chain reaction of consequent stressors that influence the well-being of older adults, with most analysis focusing on the effects of stress on mental health (Freeman et al., 2016; Tkatch et al., 2017; Mock & Eibach, 2011). This study goes beyond the scope of mental health, and expands to taking both self-rated general health and number of chronic conditions as the manifestation of stress.

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The stressor discussed in this study is “anxiety about aging” that comes from concerns and worries about growing older, and this reflects one’s fears of possible pains and losses during the aging process (Watkins, Coates, & Ferroni, 1998). Anxiety about aging is believed to be triggered by physical and mental signs of aging, with indicators such as menopause (for females), possible health issues, and fear of mortality (Barrett & Toothman, 2018; Smit et al., 2007). Historically, anxiety about aging among older adults has been a central focus of research in the field of gerontology, especially regarding how it can be used to understand the

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social basis of older adults’ functioning, as a large body of evidence has shown how subjective feelings and evaluations can influence health outcomes, both mentally and physically (Bryant et al., 2012; Dionigi, 2015; Robertson, King-Kallimanis, & Keeny, 2016).

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There is evidence showing that individuals who demonstrate more anxiety about aging tend to have poorer health status (Steptoe, Dockray, & Wardle 2009). Studies also found that

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anxiety about aging may lead to chronic health conditions such as diabetes (Blazer et al.

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2002), dementia (Ismail et al. 2018), chronic pain (De Heer et al., 2014), and heart disease (Torado, Shen, & Raffa, 2007) as well as increased risk of mortality (Ostir & Goodwin, 2006). Moreover, researchers also found that anxiety about aging co-occur or lead to mental health

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problems such as depression (Hek et al., 2011), mood and personality disorder (Mackenzie, Reynolds, Chou, Pagura, & Sareen, 2011), and cognitive impairment (Beaudreau & O’Hara,

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2008; Wilson, Begeny, Boyle, Schneider, & Bennett, 2011).

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In sum, anxiety about aging may lead to serious health consequences. There have been studies using cognitive behavior therapy to treat anxiety about aging among older adults, that is, with the help of exterior psychosocial resources (Hendriks et al., 2008; Gould, Coulson, & Howard, 2012). However, very few studies have considered interior psychosocial resources, for example, resilience, to buffer the negative influence of anxiety about aging on individual health.

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2.2 Resilience as a stress buffer As explained by Pearlin and colleagues (1981), the relationship between stressor and health is not definite and fixed as different individuals have different psychosocial coping resources that can be used to cope with stress thus modify this relationship. In this study, we consider resilience as a stress buffer that may protect individuals from the detrimental effects of stress (Cohen & Wills, 1985). As a psychosocial resource, resilience refers to an individual’s ability to recover strength and spirits, the ability to adapt positively to adversity,

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and the ability to cope with stress in a broad sense (Luthar, Cicchetti, & Becker, 2000; Richardson, 2002). Felten and Hall (2001) especially conceptualized the resilience among older adults (85+) as the ability to remain and/or recover health after illness or loss.

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Resilience is also found to be maintained during old age, thus acting as an effective and continuous psychological resource for individuals (Fontes & Neri, 2015). Therefore,

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resilience can be regarded as an optimistic psychological factor that potentially buffers the

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harmful effect of stress on individual health.

A growing body of literature focused on resilience among older adults as well as its moderating role in health-related studies. Some studies showed that resilience is positively

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related to health. Higher levels of resilience among older adults were related to optimal health outcomes such as lower levels of cognitive impairment and mortality (Bowling & Iliffe, 2011;

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Smith & Hollinger-Smith, 2013), decreased depression symptoms (Jeste et al., 2013), more

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positive attitudes towards aging (Martin, Distelberg, Palmer, & Jeste, 2015; Montross et al., 2006), improved lifestyle behaviors (Netuveli, Wiggins, Montgomery, Hildon, & Blane, 2009; Wells, 2009), as well as higher levels of psychological well-being and life satisfaction (Zhang et al., 2019). Lau and colleagues (2018) also found that levels of resilience augment self-rated health, and may shape and be shaped by other medical and social factors which influence older adults’ view of their health. Although there is no specific study concerning the

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moderating effect of resilience on the relationship between anxiety about aging and health, some limited evidence suggests that resilience may act as a stress moderator. Studies examining resilience as a moderator mostly concentrated in the field of mental health, and found that resilience could effectively moderate the relationship between stressors such as negative social interactions, caregiving-related stress, and perceived mental health problems among older adults (Shi, Wang, Bian, & Wang, 2015; Wang, Xu, Gu, Zhu, & Liang, 2019; Ong et al., 2018). This study goes beyond the domain of mental health by focusing on

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self-rated general health and number of chronic conditions as the stress outcomes.

2.3 Cultural differences

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Culture plays an important role in shaping individuals’ level of anxiety about aging. Considering high percentage of first-generation immigrants among older Chinese in the U.S.

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(Ho & Card, 2002), some comparative studies revealed that older adults in American culture

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are more positive and show less anxiety about aging when compared to their counterparts in East Asian culture (Boduroglu, Yoon, Luo, & Park, 2006; Kite, Stockdale, Whitley, & Johnson, 2005). This implies that Chinese older adults, when situated in mixed cultures,

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might have positive psychological outlooks and have lower levels of anxiety about aging compared to their peers in China. Zhang and colleagues (2018), for instance, found that

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Chinese older adults in Hawaiʻi had unique perceptions of aging that include more

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psychosocial, resilient and environmental aspects. Similarly, Wu et al. (2010) revealed that Chinese older adults in the U.S. reported lower level of depressive symptoms than their counterparts in China. On the other hand, there are also studies disclosing that perception of aging varies across cultures. For instance, Asian cultures are less ageist than Western cultures, as the Asian culture value indicates that older people should be respected and should be held in esteem (Nelson, 2009), while the Western societies often value youth, and tend to have

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more negative views about aging and older adults (North & Fiske, 2015). Therefore, it is likely that the Chinese older adults, when acculturated into U.S. culture, might suffer more from ageism perceptions than their counterparts in China. Apart from different cultural norms, there are studies showing that Chinese older adults as immigrants may not be used to the activities developed in Western cultures, and the acculturation process might be detrimental to their health (Nguyen & Seal, 2014). Some studies also revealed that Chinese older adults in the U.S. have higher levels of anxiety,

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loneliness and depression rates than the general population (Chang, Beck, Simon, & Dong, 2014; Lewis, 2009). Taken together, effects of immigrant status on levels of anxiety and health outcomes are mixed.

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In addition, levels of resilience are also influenced by cultural differences. Research shows that there are global, as well as culturally and contextually specific aspects to people’s

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lives that may shape their resilience level (Ungar, 2007). For instance, in the Chinese cultural

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context, Confucianism and Taoism deeply influence individuals’ interpretation of adversity, and emphasize inner peace as well as harmony, which would be different from Western understanding of adversity largely as pure obstacles and hurdles (Ni, Li, & Zhao 2014). The

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unique Chinese culture characteristics could cultivate higher levels of resilience among older adults in China (Hue, 2011). Therefore, Chinese older adults in China and U.S. may exhibit

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different levels of anxiety about aging, levels of resilience, and health outcomes due to

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cultural differences. In summary, as shown in Figure 1, the conceptual framework, this study aims to examine how anxiety about aging is negatively related to the health status of Chinese older adults and how resilience alleviates the detrimental effect of the former on the latter. In addition, we wish to explore the role of culture in this process by examining Chinese older adults residing in different countries.

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Resilience

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Anxiety about aging

Health status

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Fig.1. Conceptual Framework

3. Methods 3.1 Data

To answer the proposed research questions, this study utilizes survey data collected in

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Wuhan, China and Honolulu, Hawaiʻi, respectively. Wuhan is one of the first-tier cities in

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China, with a population of 10.61 million. In 2017, statistics from Wuhan Disease Control and Prevention Center show that the average life expectancy of older adults in Wuhan is

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81.09, ranking fourth in China. Data from this study were collected primarily from Jianghan district, with a population of 710,000. It was estimated that the percentage of older adults

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(aging 60+) in this district is approximately 25 percent, slightly higher than the rate of Wuhan city as a whole (22%) (Liu, Zhang, Wu, & Wu, 2019).

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Chinese in Hawaiʻi constitute close to 5% of the state’s population, and most of them (75 percent) are Cantonese with ancestors who came to Hawaiʻi in the late 18th century from

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Zhongshan city in Guangdong, China. Based on data from Hawaiʻi Department of Health, life expectancy at birth of Chinese Americans are 90 and 85.3 for females and males, respectively in 2010 (Wu et al., 2017). Data from this study were primarily collected from the city of Honolulu, and 70 percent of the respondents were first-generation immigrants. Survey inclusion criteria were consistent across two cities: 55 years of age or older, self-identified as Chinese, and able to give informed consent. Surveys in Wuhan were 10

conducted in Mandarin, whereas those in Honolulu were conducted in Mandarin, Cantonese or English. Both the English and Chinese versions of the questionnaires were prepared. In order to use accurate terms and languages in translation, we invited older Chinese adults speaking both languages to conduct some pilot interviews to make sure the translation is accurate and survey questions are understandable. After survey questions were revised and finalized according to feedback that we received from the pilot testing, we started our formal data collection. The study was approved by the institutional review boards of the institution

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to which the corresponding author belong. This study primarily used snowball and convenience sampling to recruit respondents. Specifically, in both sites, key informants were first recruited from local older adult groups,

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social organizations, businesses and faith-based agencies. Researchers then met with the selected key informants and described the aims of the research project as well as their

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expected responsibilities. Heavily relying on the connections of these key informants, the

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researchers were able to connect to local neighborhood communities in Wuhan, as well as a variety of local Chinese communities in Honolulu. This is a common recruitment strategy to outreach minority and hard-to-reach populations (Dong, Wong, & Simon, 2014), and could

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increase the sample heterogeneity. From June to August 2017, surveys were distributed in Wuhan, and a total of 850 questionnaires were collected. And from January 2018 to

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September 2018, the same surveys were distributed in Honolulu, and 430 were collected. For

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the purpose of comparison, in the Honolulu sample, only first-generation immigrants were included. After deleting random missing data, the final analytical samples of Wuhan and Honolulu are 552 and 292, respectively.

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3.2 Measures 3.2.1 Dependent Variables Individual health status was measured using self-rated health (SRH) and number of chronic conditions. SRH is considered as a reliable indicator of general health status (Bombak, 2013; Cislaghi & Cislaghi, 2019; Wu et al., 2013; Yamada, Moriyama, & Takahashi, 2015; Zajacova & Dowd, 2011), as well as a well-established predictor of mortality and other adverse health outcomes (Idler & Benyamini, 1997; Jylha, 2009).

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Moreover, it is established that its validity is increasing over time and nowadays individuals have more accurate estimations of their own health (Schnittker & Bacak, 2014). SRH in this study was measured using a five-point Likert scale, in response to the question “overall, how

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would you rate your health?” (1=very poor, 2=poor, 3=fair, 4=good, 5=very good). Likert scales have the advantage that they do not expect a simple “yes/no” answer from the

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respondent, but rather allow for degrees of opinion, and even no opinion at all (Likert, 1932).

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Therefore, when quantitative data are obtained, they provide more detailed and opinion-reflecting five-scale answers instead of dichotomous answers. Besides SRH, individual health status was also assessed using number of chronic

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conditions. Chronic conditions are commonly regarded as valid health indicators (Fortin, Haggerty, Sanche, & Almirall, 2017; Martin, Leffi, Calonge, Garrett, & Nelson, 2000).

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Number of chronic conditions is generally considered to be valid and accurate, and is a

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reasonably reliable instrument to measure ill health (Johan, Dirk, Jean and Koen, 2014). It was measured by asking respondents, “Have you been told by a doctor that you had the following medical conditions?” Ten options were provided, including coronary artery disease, stroke or brain hemorrhage, cancer, high cholesterol, diabetes, high blood pressure, a broken or fractured hip, thyroid disease, arthritis, and liver related disease. Respondents were asked to choose all that applied and the number of chronic conditions was counted as a summed index,

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ranging from zero to ten.

3.2.2 Independent Variables Two focal independent variables were included: anxiety about aging, and resilience. Anxiety about aging was also measured using the five-point Likert scale (1=not at all worry, 2=not worry, 3=somewhat worry, 4=worry, 5=very worry), in response to the following questions: Are you worrying that you might have mobility difficulties, rely on others to make

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decisions, have difficulties to pay bills, have dementia or Alzheimer’s, and become a burden to your family to take care of you as you get older? These questions were designed in reference to the Worry Scale (Wisocki, Handen, & Morese, 1986) and Aging Anxiety Scale

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(Lynch, 2000). In both the questionnaire and this study, anxiety and worry were used interchangeably because these two words share similar meaning in Chinese. Each question

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carries 1 to 5 points, so total score ranges from 5 to 25, with higher scores reflecting higher

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levels of anxiety about aging. We computed the average index of anxiety about aging, and alpha reliabilities for the Wuhan and Honolulu samples were 0.94 and 0.92, respectively. Resilience as the moderating variable was measured with the 25-item, self-rated

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Connor-Davidson Resilience Scale (CDRISC) (Campbell-Sills & Stein, 2007). The full CDRISC has good internal consistency and excellent psychometric properties for efficient

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measurement of resilience. Items were rated on a five-point Likert scale, ranging from “not

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true at all” (scored as 1) to “true nearly all the time” (scored as 5). Score ranges from 25 to 125, with higher score reflecting greater resilience. The average index was computed based on scores from the 25 items, and alpha reliabilities were 0.96 and 0.97 respectively for the Wuhan and Honolulu samples.

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3.2.3 Control Variables We controlled for socio-demographic variables such as age (in years), gender (female=1), education (college or higher =1), marital status (currently married=1), annual household income (in USD or RMB, regarding the commodity price and wage level differences of two cities, the exchange rates are not taken into consideration), smoking status (current smoker=1), and drinking status (current drinker=1).

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3.3 Statistical Analysis Analysis was performed using R Software (version 1.1.456). Descriptive statistics were summarized in Table 1. Ordered logistic regressions (Table 2) were performed with SRH as

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the dependent variable and anxiety about aging and resilience as the continuous independent variables, controlling for age, gender, education, income, marital status, smoking, and

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drinking status. Assumption checking for ordered logistic regressions was performed using R

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diagnostics packages. Models 1a and 2a included resilience as an ordinary independent variable and did not involve any interactions, while Models 1b and 2b incorporated resilience as the moderating variable. For number of chronic conditions, Poisson regressions were

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performed and results were summarized in Table 3. Models 1a and 2a of Table 3 were the

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main effect models, and Models 1b and 2b tested the moderating effect of resilience.

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4. Results

Table 1 summarizes sample characteristics. In both samples, there are more females than

males, with a percentage of almost 60 percent. There are higher percentages of non-smokers and non-drinkers in the Honolulu sample. The average age of respondents in two samples are 72 in Honolulu and 67 in Wuhan, with a 5-year difference. A higher percentage of older adults in Wuhan have an education of more than 12 years (>=college), as well as higher rate

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of being currently married. In general, older adults in both samples are in good health, with most of them rating their health as very good/good/fair, but older adults in the Honolulu sample are more likely to rate their health as very good/good health, while their counterparts in Wuhan appear to be more moderate, with more than half (53.9 percent) rating their health as fair. When it comes to number of chronic conditions, most older adults in both samples reported having none or one chronic condition, but the Wuhan sample was more concentrated in reporting having one or two chronic conditions and more older adults in Wuhan suffer

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from greater number (4-7) of chronic conditions. For both SRH and number of chronic conditions, the Honolulu sample reported significantly better health status compared to the Wuhan sample. The two samples shared different levels of resilience with a mean of 3.69 and

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3.78 for Honolulu and Wuhan, respectively. Respondents from the Wuhan sample appeared to be more anxious about aging, with an average of 3.6 points when compared to only 3.1 for

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the Honolulu sample.

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Table 2 shows results from ordered logistic regression (OLR) models for the Honolulu and Wuhan samples. The dependent variable, SRH, ranks from 1(very poor) to 5(very good) in an ascending order. The main effect models (1a and 2a) examined the effects of anxiety

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about aging and resilience on SRH, controlling for all other variables. Based on these two models, both variables are significantly associated with SRH, and both are in the expected

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direction: Resilience is positively related to SRH, whereas anxiety about aging is negatively

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related to SRH. Models 1b and 2b examined the moderating effect of resilience. Results show that both interaction terms are significant, indicating the positive moderating effect of resilience, alleviating approximately 18 percent and 13 percent (calculated based on interaction effect/main effect) of the detrimental effect of anxiety about aging on SRH respectively for the Honolulu sample and the Wuhan sample.

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Table 1. Sample characteristics for Chinese older adults in Honolulu and Wuhan Honolulu(N=292) Wuhan (N=532) Categorical Variables N (%) N (%) Sex Female 172(59.0) 323(60.7) Education ≥ College 64(21.9) 143(26.9) Married/partnered Yes 202(69.2) 405(76.1)

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Household Income USD RMB 0-24K 157 (53.8) 44 (8.3) 24-60K 38 (13.0) 206 (38.7) 60-100K 10 (3.4) 171 (32.1) 100-150K 8 (2.7) 76 (14.3) 150K+ 7(2.4) 21 (3.9) Self-rated Health Very poor 4(1.0) 10(1.9) Poor 14(3.5) 46(8.6) Fair 134(33.5) 287(53.9) Good 171(42.7) 155(29.1) Very good 77(19.2) 34(6.4) Smoking Status Never smoker 236(80.7) 366 (68.8) Past smoker 39 (13.5) 1(0.0) Current smoker 12 (4.0) 82(15.4) Drinking Status No 254 (87.0) 197(63.0) Number of Chronic Conditions 0 100(34.1) 128(24.1) 1 101(34.7) 215(40.5) 2 56(19.3) 113(21.2) 3 28(9.6) 44(8.3) 4-7 7(1.9) 32(5.7) Continuous Variables mean(SD) mean(SD) Age 72.2 (9.3) 67.2 (6.9) *** Resilience 3.69 (0.8) 3.78 (0.8) * Anxiety about aging 3.1 (0.9) 3.6 (1.0) *** Self-rated health 3.6(0.8) 2.7(0.8) *** Number of chronic conditions 1.1(1.1) 1.4(1.2) ** Notes: 1. Variables SRH and number of chronic conditions were also considered as continuous variables shown at the bottom of the table. . Independent sample T-tests were carried out on continuous variables. *P< .05; **P< .01; ***P< .001

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Fig.2. Visualization of Moderating effects of Resilience on Self-rated health by City

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Figure 2 visualizes the moderating effects of resilience on SRH for Wuhan and

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Honolulu. The red dotted lines indicate the relationship between anxiety about aging and self-rated health with an average level of resilience (3.69 and 3.78 for the Honolulu and

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Wuhan samples, respectively). The green dotted lines and black full lines demonstrate the relationship between anxiety about aging and self-rated health when there’s one standard

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deviation (SD) increase or decrease from the average level of resilience. The deviance from the average (the red dotted line) indicates the moderating effect of resilience, as the two

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samples share similar SD of resilience, as shown in Table 1. Overall, for both samples, older adults with higher levels of resilience were less likely to be influenced by anxiety about aging,

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and this reconfirms the moderating role of resilience. Moreover, the steeper and more divergent lines in figure (a) suggest that the moderating effect was stronger in the Honolulu sample. In other words, compared to their counterparts in Wuhan, older adults in Honolulu are likely to be affected more by levels of resilience.

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Table 2. Ordered Logit Regressions by City (Honolulu and Wuhan): Regress self-rated health on resilience, anxiety about aging, and control variables. Honolulu(foreign-born) Wuhan N=292 N=532 main effects Model 1a

resilience*anxiety Model 1b

main effects Model 2a

resilience*anxiety Model 2b

-.447(.287)

-.439(.287)

.180(.298)

.171(.297)

.050(.177)

.052(.177)

.088(.540) -.035(.553) .566(.609) .314(.826)

.018(.543) -.081(.554) .496(.613) .279(.824)

-.572(.329)*

-.576(.329)*

.036(.039)

.039(.039)

-p -.036(.018)* .604(.171)*** -.475(.131)***

-.037(.018)* .219(.488) -.963(.593)* .122(.144)*

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Female .071(.270)*** .061(.269) Education ≥ College .490(.336)*** .517(.337) Married/partnered Yes .030(.143)*** .032(.144) Household income 24-60K .520(.388)*** .559(.388) 60-100K -.019(.732)*** .084(.741) 100-150K .723(.732)*** .821(.736) 150K+ 1.237(.774)*** 1.285(.773)* Smoking status Current/past smoker .291(.620)*** .116(.624) Drinking status No .351(.113)*** .335(.111)** Continuous Variables Age -.011(.015)*** -.011(.015) Resilience .753(.171)*** -.041(.454) Anxiety about aging -.534(.144)*** -.148(.531)** Interactions resilience*anxiety .263(.141)* Notes: +P< .10; *P< .05; **P< .01; ***P< .001.

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Categorical Variables Sex

Table 3 shows results from Poisson regression models. The health outcome in the table

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is “number of chronic conditions,” while all other independent variables remain the same as those in Table 2. Consistent with findings from the OLR models for both samples, the

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variable “anxiety about aging” is significant in the main effect models (1a and 2a) and the association between anxiety about aging and number of chronic conditions is in the expected

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direction: Higher levels of anxiety is related to more chronic conditions. However, both the main effect of resilience in the Wuhan sample and the interaction between resilience and anxiety about aging are not significant, and the main effects of anxiety about aging also become insignificant in both models. These findings suggest that resilience does not buffer the negative association between anxiety about aging and number of chronic conditions for both samples. 18

Table 3. Poisson Regressions by City (Honolulu and Wuhan): Regress number of chronic conditions on resilience, anxiety about aging, and control variables. Honolulu(foreign-born) Wuhan N=292 N=532 main effects Model 1a

resilience*anxiety Model 1b

main effects Model 2a

resilience*anxiety Model 2b

.159(.124)

.158(.124)

-.019(.133)

-.073(.223)

.057(.076)

.059(.076)

-.197(.191) -.048(.201) .179(.227) -.138(.371)

-.178(.195) -.036(.203) .196(.231) -.134(.371)

.056(.149)

.054(.149)

.009(.015)

.008(.015)

.023(.007)** -.029(.070) .211(.055)***

.023(.008)** .073(.223) .323(.240)

-.029(.060)

-p

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5. Discussion

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Female -.055(.130) .-.053(.130) Education ≥ College -.356(.177)* -.348(.187)* Married/partnered Yes .024(.070) .023(.070) Household income -.113(.192) -.112(.192) 24-60K 60-100K .117(.382) .155(.384) 100-150K .351(.323) .373(.324) 150K+ .244(.381) .250(.381) Smoking status Current/past .480(.347) .454(347) smoker Drinking status No .065(.043) .060(.043) Continuous Variables Age .001(.007) .001(.061) Resilience -.160(.076)* -.365(.204) Anxiety about .165(.065)* -.061(.219) aging Interactions resilience*anxiety .065(.061) Notes: +P< .10; *P< .05; **P< .01; ***P< .001.

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Categorical Variables Sex

This study examines the association between anxiety about aging and individual health

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status and explores the moderating role of resilience under two cultural backgrounds. Results show that, for both Honolulu and Wuhan samples, anxiety about aging is associated with

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lower levels of health (both SRH and number of chronic conditions), and this echoes previous studies on the detrimental health effect of anxiety about aging (Gellis et al., 2014). These results indicate that anxiety about aging indeed can act as a stressor and exerts detrimental influence on individual health, and this is in accordance with Pearlin and colleagues’ statement that stressors produce an internal arousal, resulting in external circumstances that challenge the individual health (1981). Consistent with findings of Wu and colleagues (2010), 19

it is found that the Honolulu respondents exhibited lower levels of anxiety about aging, however, they were more susceptible to anxiety about aging. One possible explanation comes from Cheung et al., (2001): For immigrants, their personality was defined not just by what they had developed in China, but also by the cultural contexts in the U.S., therefore the hybrid personality tends to be less steadfast and more susceptible to changes. Moreover, as suggested by Bryant et al. (2012), individuals tend to utilize available psychosocial resources and generate effective coping response to cope with anxiety. In our

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models, resilience, as the moderating factor, is found to buffer the detrimental effect of anxiety about aging for both samples, in accordance with the positive influence that resilience might exert on health outcomes (Smith & Hollinger-Smith, 2015; Bowling & Iliffe, 2011).

-p

Results show that with the interference of resilience, the influence that anxiety about aging exerts on individual health reduces substantially. Going back to the definition and

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health-benefiting characteristics of resilience, we speculate that its self-restoring and

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adaptability features may contribute to the buffering effect. This is also consistent with what Pearlin and colleagues (1981) proposed about moderators, that is, the stress-buffer effect

effects of stressors.

na

could reinforce self-identity and increase the capacity to protect individuals from the negative

Although the resilience level of the Honolulu sample is lower than that of the Wuhan

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sample, its moderating effect is more substantial for older adults in Honolulu. This finding

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not only reconfirms resilience’s role as a psychosocial resource as well as a stress buffer (Zhang et al., 2019), but also indicates that resilience as a psychosocial resource in combating anxiety about aging might work more effectively for older adults in Honolulu. This difference might be explained by different kinds of psychosocial resources utilized by older adults in different cultural contexts. For instance, Liu et al. (2019) described that older adults in Wuhan experienced more intergenerational transfers and utilized more

20

external, family

support-related resources than their U.S. counterparts. This is in accordance to the traditional family values and culture norms in China (Guo, Steinberg, Dong, & Tiwari, 2018; Zhang, Chen, & Feng, 2015). In comparison, older adults in the Honolulu sample tend to be more independent and rely more heavily on internal psychosocial resources to cope with stressors. Nevertheless, the buffering effect of resilience only works for SRH, and is not significant for chronic conditions, and this difference might be explained from two perspectives. The first has to do with the disparity between the two measures of health status,

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SRH (a more subjective measure of health) and number of chronic conditions (a more objective measure of health). There are systematic differences and bias between objective and subjective measures of health (Johnston, Propper, & Shields, 2009), and it is worth

-p

mentioning that apart from self-rated health, level of resilience is also a more subjective measure and has the characteristics of subjectivity (Jones, 2019). This might contribute to its

re

concurrence with SRH, but not so much with number of chronic conditions. Secondly, this

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discrepancy does not mean that psychosocial resources cannot be used to influence chronic conditions, as studies show that different psychosocial measures are indeed important to combat individual biological, psychological and sociological targets (Deter, 2012). The

na

insignificance of resilience purports that there might be other psychosocial resources, such as family support and social group engagement that could more effectively buffer the influences

ur

of anxiety about aging (Williams, Schneiderman, Relman, & Angell, 2002), or that resilience

Jo

might influence chronic conditions indirectly through other factors that are not included in this study.

Meanwhile, it should be noted that individual health is better for the Honolulu sample

than for the Wuhan sample, whether measured in SRH or number of chronic conditions. We speculate that both immigrant status and culture-related reasons may explain the differences. First, according to the immigration selection theory, on average, the migrating group is

21

healthier than their peers from country of origin, so that they are more likely to adapt to the acculturation process and find jobs (Akresh & Frank, 2008). Second, the difference can also be explained by other lifestyle–related factors. For example, there are lower percentages of alcohol-drinkers and smokers in the Honolulu sample. We speculate that this lifestyle difference may be partially due to the differences in culture, regulations, and environment. In most public places of the U.S., smoking and drinking are prohibited, and this might lead to the decreased use of cigarette and alcohol (Bobo & Husten, 2000; Daskalopoulou et al.,

ro of

2018). One systematic review of Asian Americans found that there was a negative association between acculturation and smoking, implying the gradual decrease of smoking behaviors for immigrants (Zhang & Wang, 2008); whereas in China, the control and prohibition started late

-p

in 2006 and remain quite loose, and smoking as well as drinking remain as important public health issues in China (Liu et al., 2016; Zhang & Wu, 2015).

re

And lastly, exposure to multiple cultures may contribute to this difference. Corlin and

lP

colleagues (2014) reported that Chinese immigrants tended to retain the living habits after immigration and lived in ethnic enclaves such as Chinatown to preserve their cultural practices such as engaging in more physical exercises and healthy diet (Rosenmoller, Gasevic,

na

Seidell, & Lear; Tseng, Wright, & Fang, 2015). At the same time, it is possible that the older Chinese immigrants would gradually acculturated into American society, considering the

ur

daily contacts and social interaction needs, despite the fact that most of them cluster in

Jo

Chinatown. They might gradually pick up Western norms such as valuing more financial as well as physical independence and being freed from family burdens, therefore ending up with more autonomy with their time and money to entertain themselves (Chappell & Kusch, 2007; Ip, Lui, & Chui, 2007; Lin, Bryant, & Boldero, 2015; Wong, Yoo, & Stewart, 2006). In this sense, compared to their Wuhan counterparts, older Chinese immigrants in the Honolulu sample are likely to take advantage of the healthy behaviors from both cultures. This echoes

22

the hypothesis put forward by Vaughn and colleagues (2009) who stated that co-existing diverse cultures may produce better health outcomes. It seems that for Chinese older adults in the U.S., the availability of various cultural resources may be beneficial for their health and well-being. Due to the constraints of sampling strategies and data, this study has its inevitable limitations. In terms of the external validity, findings from this study may not be generalized to older adults living in other parts of China and the U.S. In addition, the cross-sectional

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nature of our data prevents us from making causal inferences with regards to the focal relationships. Also, some important variables such as social support, self-esteem, and sense of personal control are missing in the data sets. And this limits our ability to comprehensively

-p

compare and contrast the effects of different psychosocial resources on individual health

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status among Chinese older adults.

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6. Conclusion

To sum up, this study reveals the adverse relationship between anxiety about aging and individual health status as well as the stress buffering role of resilience under two cultural

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backgrounds. However, the moderating effect of resilience was only found to be effective for SRH, but not for number of chronic conditions for individuals in both cultural contexts.

ur

Compared to older adults in Wuhan, Chinese older adults in Honolulu showed lower levels of

Jo

anxiety about aging and lower levels of resilience, but for them, anxiety about aging resulted in more detrimental health consequences and resilience played a more substantial role in buffering its detrimental effect. The importance of psychosocial resource such as resilience in buffering the adverse influences on the subjective health outcome highlights the need for social policies that promote levels of resilience, for instance improving physical, social and institutional infrastructure as interventions. Moreover, providing older adults with access to

23

health information as well as key public services, increasing their social connectedness and ensuring civic freedom are all critical policy development directions. Also, it would be important for healthcare professionals to provide more educational programs at clinical and community-settings to decrease level of anxiety toward aging by promoting healthy aging and combating ageism.

Financial Support

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This study was supported by a research grant from the Rory Meyers College of Nursing at New York University.

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Ethical Standards

The research design received full ethical approval from the University of Hawaiʻi at Mānoa,

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Institutional Review Boards.

Statement of Conflict of Interest

The authors declare no conflict of interest

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Declaration of interests

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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References: Ahern, N. R., Kiehl, E. M., Sole, M. L., & Byers, J. (2006). A review of instruments measuring resilience. Issues in Comprehensive Pediatric Nursing, 29, 103–125. Akresh, I. R., & Frank, R. (2008). Health selection among new immigrants. American Journal of Public Health, 98, 2058–2064.

ro of

Andreescu, C., & Varon, D. (2015). New research on anxiety disorders in the elderly and an update on evidence-based treatments. Current Psychiatry Reports, 17, 53. doi: 10.1007/s11920-015-0595-8

-p

Aneshensel, C. S., & Avison, W. R. (2015). The stress process: an appreciation of Leonard I. Pearlin. Society and Mental Health, 5(2), 67–85.

re

Baker, M., Stabile, M., & Deri, C. (2004). What do self-reported, objective, measures of

lP

health measure? Journal of Human Resources, 39(4), 1067-1093. Barret, A. E., & Toothman, E. L. (2018) Multiple “old ages”: The influence of social context on women’s aging anxiety. The Journals of Gerontology: Series B, Psychological

na

Sciences and Social Sciences, 73(8), e154-e164. Beaudreau, S. A., & O’Hara, R. (2008). Late-life anxiety and cognitive impairment: A review.

ur

The American Journal of Geriatric Psychiatry, 16 (10), 790-803.

Jo

Blazer, D., Moddy-Ayers, D., Craft-Morgan, J., & Burchett, B. (2002). Depression in diabetes and obesity: racial/ethnic/gender issues in older adults. Journal of Psychosomatic Research, 52, 1-4.

Bobo, J. K., & Husten, C. (2000). Sociocultural Influences on Smoking and Drinking. Alcohol Research and Health, 24(4):225-32. Boduroglu, A., Yoon, C., Luo, T., & Park, D. (2006). Age-related stereotypes: a comparison of

25

American and Chinese Cultures. Gerontology, 52, 324-333. doi: 10.1159/000094614. Bombak, A. E. (2013). 2013. Self-rated health and public health: A critical perspective. Front Public Health, 1: 15. doi: 10.3389/fpubh.2013.00015 Bowling, A., & Iliffe, S. (2011). Psychological approach to successful ageing predicts future quality of life in older adults. Health and quality of life outcomes, 9, 13. doi:10.1186/1477-7525-9-13 Bryant, C., Bei, B., Gilson, K., Komiti, A., Jackson, H., & Judd, F. (2012). The relationship

ro of

between attitudes to aging and physical and mental health in older adults. International Psychogeriatrics, 24(10), 1674-1683. doi: 10.1017/S1041610212000774

-p

Byers, A. L., Yaffe, K., Covinsky, K. E., Friedman, M. B., & Bruce, M. L. (2010). High occurrence of mood and anxiety disorders among older adults. Archives of General

re

Psychiatry, 67 (5), 489-496. doi: 10.1001/archgenpsychiatry.2010.35.

lP

Campbell-Sills, L., & Stein, M. B. (2007). Psychometric analysis and refinement of the Connor-davidson Resilience Scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Trauma Stress, 20(6), 1019-1028.

na

Chang, E. S., Beck, T., Simon, M. A., & Dong, X. (2014). A psychometric assessment of the psychological and social well-being indicators in the PINE study. Journal of Aging and

ur

Health, 26, 1116–1136. doi:10.1177/0898264314543471

Jo

Chappell, N. L. & Kusch, K. (2007). The gendered nature of filial piety: A study among Chinese Canadians. Journal of Cross-Cultural Gerontology, 22, 29-45. doi: 10.1007/s10823-006-9011-5

Cheung, F. M., Leung, K., Zhang, J. X., Sun, H.F., Gan, Y.Q., Song, W.Z., & Xie, D. (2001). Indigenous Chinese Personality Constructs: Is the Five-Factor Model Complete? Journal of Cross-Cultural Psychology, 32(4), 407–433. doi: 10.1177/0022022101032004003 26

Cislaghi, B., & Cislaghi, C. (2019). Self-rated health as a valid indicator for health-equity analyses: evidence from the Italian health interview survey. BMC public health, 19(1), 533. doi:10.1186/s12889-019-6839-5 Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310–357. Corlin, L., Woodin, M., Thanikachalam, M., Lowe, L., & Brugge, D. (2014). Evidence for the healthy immigrant effect in older Chinese immigrants: a cross-sectional study. BMC

ro of

Public Health, 14, 603. Crocq, M. A. (2003). Alcohol, nicotine, caffeine, and mental disorders. Dialogues in clinical neuroscience, 5(2), 175–185.

-p

Daskalopoulou, C., Stubbs, B., Kralj, C., Koukounari, A., Prince, M., & Prina, A. M. (2018). Associations of smoking and alcohol consumption with healthy ageing: a systematic and

meta-analysis

of

longitudinal

re

review

studies.

BMJ

lP

Open 2018;8:e019540. doi: 10.1136/bmjopen-2017-019540 De Beurs, E., Beekman, A., van Balkom, A., Deeg, D., van Dyck, R., & van Tilburg, W. (1999). Consequences of anxiety in older persons: Its effect on disability, well-being and use of

na

health services. Psychological Medicine, 29 (3), 583-593. De Heer, E. W., Gerrits, M. M., Beekman, A. T., Dekker, J., van Marwijk, H. W., de Waal, M.

pain:

Jo

with

ur

W., … van der Feltz-Cornelis, C. M. (2014). The association of depression and anxiety a

study

from

NESDA. PloS

one, 9(10),

e106907.

doi:

10.1371/journal.pone.0106907

Deter,

H.

C.

(2012).

Psychosocial

interventions

for

patients

with

chronic

disease. BioPsychoSocial medicine, 6(1), 2. doi:10.1186/1751-0759-6-2 Dionigi, R. A. (2015). Stereotypes of aging: their effects on the health of older adults. Journal of Geriatrics, 15, 1-9. doi: 10.1155/2015/954027.

27

doi: 10.1177/2156869315585388 Dong, X., Wong, E., & Simon, M. A. (2014). Study design and implementation of the PINE study. Journal of Aging and Health, 26(7), 1085-1099. Erica, L. O., Hess, T. M., Kornadt, A. E., Rothermund, K., Fung, H., & Voss, P. (2017). Context influences on the subjective experience of aging: the impact of culture and domains of functioning. The Gerontologist, 57(suppl_2), 127–137. doi: 10.1093/geront/gnx015

ro of

Felten, B. S., & Hall, J. M. (2001) Conceptualizing resilience in women older than 85. Journal of Gerontological Nursing, 27, 46-53.

Flint, A. J. (2005). Anxiety and its disorders in late life: moving the field forward. American

-p

Journal of Geriatric Psychiatry, 13(1), 3–6. doi: 10.1097/00019442-200501000-00002 Fontes, A. P., & Neri, A. L. (2015). Resilience in aging: literature review. Ciência & Saúde

re

Coletiva, 20(5), 1475-1495. doi: 10.1590/1413-81232015205.00502014

lP

Fortin, M., Haggerty, J., Sanche, S., & Almirall, J. (2017). Self-reported versus health administrative data: Implications for assessing chronic illness burden in populations. A cross-sectional study. CMAJ open, 5(3), 729–733.

na

doi:10.9778/cmajo.20170029

Freeman, A. T., Santini, Z. i., Tyrovolas, S., Kluge, C. R., Haro, J. M. & Koyanagi, A. (2016).

ur

Negative perceptions of ageing predict the onset and persistence of depression and

Jo

anxiety: Findings from a prospective analysis of the Irish Longitudinal Study on Ageing (TILDA). Journal of Affective Disorders, 199(15), 132-138.

Gellis, Z.D., Kim, E., & McCracken, S. (2014). Review of Anxiety disorders in older adults. In S. Diwan (Ed.), Mental Health and Older Adults Resource Reviews. Council of Social Work Education, Geriatrics Education Center. Gierveld, J. D. J., Van der Pas, S., & Keating, N. (2015). Loneliness of older immigrant

28

groups in Canada: effects of ethnic-cultural background. Journal of Cross-Cultural Gerontology, 30(3): 251–268. doi: 10.1007/s10823-015-9265-x Goncalves, D. C., Pachana, N. A., & Byrne, G. J. (2011). Prevalence and correlates of generalized anxiety disorder among older adults in the Australian National Survey of Mental Health and Well-Being. Journal of Affective Disorders, 132, 223-230. Gooding, P. A., Hurst, A., Johnson, J., & Tarrier, N. (2012). Psychological resilience in young and older adults. International Journal of Geriatric Psychiatry, 27, 262-270.

ro of

Gould, R. L., Coulson, M. C., & Howard, R. J. (2012). Efficacy of cognitive behavioral therapy for anxiety disorders in older people: A meta-analysis and meta-regression of randomized controlled trials. The American Geriatrics Society, 60, 218-229. doi:

-p

10.1111/j.1532-5415.2011.03824.x.

Guo, M., Steinberg, N. S., Dong, X., & Tiwari, A. (2018). A cross-sectional study of coping

lP

Health, 22(11), 1448-1455.

re

resouces and mental health of Chinese older in the United States. Aging & Mental

Hek, K., Tiemeier, H., Newson, R. S., Luijendijk, H. J., Hofman, A., & Mulder, C. L. (2011). Anxiety disorders and comorbid depression in community dwelling older adults.

na

International Journal of Methods in Psychiatric Research, 20 (3), 157-168. Hendriks, G.J., Keijsers, G.P., Kampman, M., Oude Voshaar, R.C., Verbraak, M.J., Broekman,

ur

T.G., & Hoogduin, C.A. (2010). A randomized controlled study of paroxetine and therapy

for late-life

panic

disorder.

Acta

Psychaitrica

Jo

cognitive-behavioural

Scandinavica, 122, 11-19. doi: 10.1111/j.1600-0447.2009.01517.x.

Ho, C., & Card, J. A. (2002). Older Chinese women immigrants and their leisure experiences: before and after emigration to the United States. In: T. Sharon (Eds.), Proceedings of the 2001 Northeastern Recreation Research Symposium (pp. 291-297). Newtown Square, PA: U.S. Department of Agriculture, Forest Service, Northeastern Research Station.

29

Hue, M. (2011). Developing resiliency in students with behavioral problems in Hong Kong secondary schools: teachers’ narratives from a school guidance perspective. Pastor Care in Education, 29(4):261-272. Idler. E. L. & Benyamini, Y. 1997. Self-rated health and mortality: a review of twenty-seven community studies. Journal of Health and Social Behavior, 38(1): 21–37.

Ip, D., Lui, C. W., & Chui, W. H. (2007). Veiled entrapment: A study of social isolation of older Chinese migrants in Brisbane, Queensland. Ageing and Society, 27, 719-738. doi:

ro of

10.1017/S0144686X07006083 Ismail, Z., Gatchel, J., Bateman, D., Barcelos-Ferreira, R., Cantillon, M., Jaeger, J., . . . Mortby, M. (2018). Affective and emotional dysregulation as pre-dementia risk markers:

euphoria. International

10.1017/S1041610217001880

Psychogeriatrics, 30(2),

185-196.

doi:

re

and

-p

Exploring the mild behavioral impairment symptoms of depression, anxiety, irritability,

lP

Jeste, D. V., Savla, G. N., Thompson, W. K., Vahia, I. V., Glorioso, D. K., Martin, A. S., … Depp, C. A. (2013). Association between older age and more successful aging: critical role of resilience and depression. The American journal of psychiatry, 170(2), 188–196.

na

doi: 10.1176/appi.ajp.2012.12030386

Johan, V. H., Dirk, D. B., Jean, T., & Koen, V. H. 2014. Reliability and validity of a global

ur

question on self-reported chronic morbidity. Journal of Public Health (Berlin), 22(4):

Jo

371-380.

Johnston, D. W., Propper, C., & Shields, M. A. (2009) Comparing subjective and objective measures of health: Evidence from hypertension for the income/health gradient. Journal of Health Economics, 28(3), 540-552. Jones, L. (2019). Resilience isn't the same for all: comparing subjective and objective approaches to resilience measurement. WIREs Climate Change, 10, 552.

30

doi: 10.1002/wcc.552 Judge, K., Heather, L. M., & Whitlatch, C. J. (2009). Stress process model for individuals with dementia. The Gerontologist, 50, 294-302. doi:10.1093/geront/gnp162. Jylha, M. 2009. What is self-rated health and why does it predict mortality? Towards a unified conceptual

model. Social

Science

&

Medicine,

69(3):307–16.

doi:10.1016/j.socscimed.2009.05.013 Kite, M., Stockdale, G., E. Whitley Jr, B., & Johnson, B. (2005). Attitudes toward younger and

ro of

older adults: an updated meta‐analytic review. Journal of Social Issues, 61, 241 - 266. doi: 10.1111/j.1540-4560.2005.00404.x.

Lasher, K. P., & Faulkender, P. J. (1993). Measurement of aging anxiety: Development of the

-p

anxiety about aging scale. The International Journal of Aging and Human Development, 37,247-259.

re

Lau, S. Y. Z., Guerra, R., Barbosa, J., & Phillips, S, (2018). Impact of resilience on health in

lP

older adults: A cross-sectional analysis from the International Mobility in Aging Study (IMIAS). BMJ Open, 8(11), e023779.

na

Lenze, E. J., & Wetherell, J. L. (2011). Anxiety disorders: new developments in old age. The American Journal of Geriatric Psychiatry, 19(4), 301–304. doi:10.1097/JGP.0b013e31820db34f

ur

Lewis, D. C. (2009). Aging out of place: Cambodian refugee elders in the United

Jo

States. Family and Consumer Sciences Research Journal, 37, 376–393. doi: 10.1177/1077727X08330684.

Likert, R. (1932). A technique for measurement of attitudes. Archives of Psychology, 140, 5-55. Lin, X., Bryant, C., & Boldero, J. (2015). Older Chinese immigrants’ relationships with their children: A literature review from a solidarity-conflict perspective. The Gerontologist,

31

55(6):990-1005. doi: 10.1093/geront/gnu004 Liu, S., Zhang, M., Yang, L., Li, Y., Wang, L., Huang, Z., … Zhou, M. (2017). Prevalence and patterns of tobacco smoking among Chinese men and women: findings of the 2010 national smoking survey. Journal of Epidemiology & Community Health, 71: 154-161. Liu, S., Zhang, W., Wu, L.-H., & Wu, B. (2019). Contributory behaviors and life satisfaction among Chinese older adults: exploring variations by gender and living arrangement. Social Science & Medicine, 229, 70-78.

ro of

Löckenhoff, C. E., De Fruyt, F., Terracciano, A., McCrae, R. R., De Bolle, M., Costa, P. T., Jr, … Yik, M. (2009). Perceptions of aging across 26 cultures and their culture-level associates. Psychology and aging, 24(4), 941–954.

-p

doi:10.1037/a0016901

Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical

lP

10.1111/1467- 8624.00164

re

evaluation and guidelines for future work. Child Development, 71(3), 543–562. doi:

Lynch, S. M. (2000). Measurement and prediction of aging anxiety. Research on Ageing, 22, 533–558. doi:10.1177/0164027500225004.

na

Mackenzie, C. S., Reynolds, K., Chou, K. L., Pagura, J., & Sareen, J. (2011). Prevalence and correlates of generalized anxiety disorder in a national sample of older adults. The

ur

American Journal of Geriatric Psychiatry, 19, 305-315.

Jo

Mancini, A. D., & Bonanno, G. A. (2006). Resilience in the face of potential trauma: Clinical 
practices and illustrations. Journal of Clinical Psychology, 62(8), 971-985. 


Martin, A., Distelberg, B., Palmer, B & V. Jeste, D. (2014). Development of a new multidimensional individual and interpersonal resilience measure for older adults. Aging & Mental Health, 19, 1-14. doi: 10.1080/13607863.2014.909383. Martin, L. M., Leffi, M., Calonge, N., Garrett, C., & Nelson, D. E. (2000). Validation of

32

self-reported chronic conditions and health services in a managed care population. American

Journal

of

Preventitive

Medicine,

18(3),

215-218.

doi:

10.1016/S0749-3797(99)00158-0 Martinez, J. N., Aguayo-Tellez, E., & Rangel-Gonzalez, E. (2015). Explaining the Mexican-American health paradox using selectivity effects. International Migration Review, 49, 878–906. Masten, A. S. (2014). Global perspectives on resilience in children and youth. Child

ro of

Development, 85, 6–20. Mock, S. E., & Eibach, R. P. (2011). Aging attitudes moderate the effect of subjective age on psychological well-being: Evidence from a 10-year longitudinal study. Psychology and

-p

Aging, 26(4), 979-986. doi: 10.1037/a0023877

Montross, L. P., Depp, C., Daly, J., Reichstadt, J., Golshan, S., Moore, D., …Jeste, D. V.

American

Journal

of

Geriatric

Psychiatry,

14(1),

43-51.

doi:

lP

adults.

re

(2006). Correlates of self-rated successful aging among community-dwelling older

10.1097/01.JGP.0000192489.43179.31.

Nelson, T. D. (2009). Ageism. In Nelson, T. D. (Eds), Handbook of Prejudice, Stereotyping,

na

and Discrimination (pp. 431-440). New York, NY: Psychology Press. Netuveli, G., Wiggins, R. D., Montgomery, S. M., Hildon, Z., & Blane, D. (2008). Mental

ur

health and resilience at older ages: Bouncing back after adversity in the British

Jo

Household Panel Survey. Journal of Epidemiological Community Health, 62, 987-991. Nguyen, A. L., & Seal, D. W. (2014) Cross-cultural comparison of successful aging definitions between Chinese and Hmong elders in the United States. Journal of Cross-Cultural Gerontology, 29(2): 153–171. doi: 10.1007/s10823-014-9231-z Ni, H., Li, C., & Zhao, J. (2014). Cultural consideration of resilience for Chinese immigrant children and adolescents. North American Journal of Medicine and Science, 7(3),

33

112-117. North, M. S., & Fiske, S. T. (2015). Modern attitudes toward older adults in the aging world: a

cross-cultural

meta-analysis.

Psychological

Bulletin,

141(5):

993-1021.

doi:10.1037/a0039469 O’Brein, E. L., Hess, T. M., Kornadt, A. E., Rothermund, K., Fung, H., & Voss, P. (2017). Context influences on the subjective experience of aging: The impact of culture and domains of functioning. The Gerontologist, 57(suppl_2), 127–137.

ro of

Ong, H. L., Vaingankar, J. A., Abdin, E., Sambasivam, R., Fauziana, R., Tan, M. E., … Subramaniam, M. (2018). Resilience and burden in caregivers of older adults: Moderating and mediating effects of perceived social support. BMC psychiatry, 18(1), 27.

-p

doi:10.1186/s12888-018-1616-z

Ostir, G. V., & Goodwin, J. S. (2006). Anxiety in persons 75 and older: Findings from a

re

tri-ethnic population. Ethnicity & Disease, 16 (1), 22-27.

lP

Pearlin, L. I., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process. Journal of Health and Social Behavior, 22(4), 337-356. doi: 10.2307/2136676 Pinquart, M., & Duberstein, P. R. (2007). Treatment of anxiety disorders in older adults: a

na

meta-analytic comparison of behavioral and pharmacological interventions. American Journal of Geriatric Psychiatry, 15(8), 639–651.

ur

doi:10.1097/JGP.0B013e31806841c8

Jo

Potvin, O., Forget, H., Grenier, S., Preville, M., & Hudon, C. (2011). Anxiety, depression, and 1-year incident cognitive impairment in community-dwelling older adults. The Journal of American Geriatric Society, 59, 1421-1428.

Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58(3), 307–321.

34

Richardson, T. M., Simning, A., He, H., & Conwell, Y. (2011). Anxiety and its correlates among older adults accessing aging services. International Journal of Geriatric Psychiatry, 26(1), 31–38. DOI:10.1002/gps.2474 Robertson, D. A., King-Kallimanis, B. L., & Kenny, R. A. (2016). Negative perceptions of aging predict longitudinal decline in cognitive function. Psychology and Aging, 31(1), 71-81. doi: 10.1037/pag0000061 Rosenmollder, D. L., Gasevic, D., Seidell, J., & Lear, S. A. (2011). Determinants of changes in

ro of

dietary patterns among Chinese immigrants: A cross-sectional analysis. International Journal of Behavioral Nutrition and Physical Health, 8: 42. doi: 10.1186/1479-5868-8-42 Schnittker, J., & Bacak, V. (2014). The increasing predictive validity of self-rated health.

-p

PloS ONE, 9(1): e84933.

Comparative Sociology, 5, 1136-182.

lP

doi: 10.1163/156913306778667357

re

Schwartz, S. H. (2006). A theory of cultural value orientations: explication and applications.

Shen, K., & Zeng, Y. (2010). The association between resilience and survival among Chinese

na

elderly. Demographic Research, 23(5),105-116. 
 Shi, M., Wang, X., Bian, Y., & Wang, L. (2015). The mediating role of resilience in the

ur

relationship between stress and life satisfaction among Chinese medical students: a cross-sectional study. BMC Medical Education, 15(1), 297.

Jo

doi: 10.1186/s12909-015-0297-2 Smit, F., Comijs, H., Schoevers, R., Cujipers, P., Deeg, D., & Beekman, A. (2007). Target groups for the prevention of late-life anxiety. British Journal of Psychiatry, 190, 428– 434. Smith, D. M., Langa, K. M., Kabeto, M. U., & Ubel, P. A. (2005). Health, wealth and happiness: Financial resources buffer subjective well-being after the onset of a disability.

35

Psychological Science, 16, 663–666. Smith, J. L., & Hollinger-Smith, L. (2015). Savoring, resilience, and psychological well-being in older adults. Aging & Mental Health, 19(3), 192-200. doi: 10.1080/13607863.2014.986647 Steptoe, A., Dockray, S., & Wardle, J. (2009). Positive affect and psychobiological processes relevant to health. Journal of Personality, 77(6), 1747–1776. doi: 10.1111/j.1467-6494.2009.00599.x

ro of

Tkatch, R., Musich, S., MacLeod, S., Kraemer, S., Hawkins, K., Wicker, E. R., & Armstrong, D. G. (2017). A qualitative study to examine older adults' perceptions of health: Keys to aging successfully. Geriatric Nursing, 38(6), 485-490.

-p

doi: 10.1016/j.gerinurse.2017.02.009.

Torado, J. F., Shen, B. J., & Raffa, S. D. (2007). Prevalence of anxiety disorders in men and

re

women with established coronary heart disease. Journal of Cardiopulmonary

lP

Rehabilitation, 27, 86–91.

Tseng, M., Wright, D. J., & Fang, C. Y. (2015). Acculturation and dietary change among Chinese immigrant women in the United States. Journal of Immigrant and Minor Health,

na

17(2):400-407. doi: 10.1007/s10903-014-0118-4 Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to

ur

bounce back from negative emotional experiences. Journal of Personality and Social

Jo

Psychology, 86(2), 320-333. Ungar, M. (2008). Resilience across Cultures. The British Journal of Social Work, 38(2), 218– 235. doi: 10.1093/bjsw/bcl343

Vaughn, L. M., Jacquez, F., & Baker, R. (2009). Cultural health attributions, beliefs and practices: effects on healthcare and medical education. The Open Medical Education Journal, 2, 64-74.

36

Wang, L., Xu, B., Gu, Y., Zhu, J., & Liang, Y. (2019). The mediating and moderating effects of resilience on the relationship between perceived stress and depression in heroin addicts. Journal of Community, 47, 495– 503. doi: 10.1002/jcop.22133 Watkins, R. E., Coates, R., & Ferroni, P. (1998). Measurement of aging anxiety in an elderly Australian population. International Journal of Aging & Human Development, 46, 319– 332. doi: 10.2190/ 0LU1-0UWE-2TLW-QVAP. Wells, M. (2009). Resilience in rural community-dwelling older adults. Journal of Rural

ro of

Health, 25(4), 415-419. Williams, R., Schneiderman, N., Relman, A., & Angell, M. (2002). Resolved: Psychosocial interventions can improve clinical outcomes in organic disease--rebuttals and closing

doi: 10.1097/01.PSY.0000023412.02546.CF.

-p

arguments. Psychosomatic Medicine, 64(4), 564–7.

re

Wilson, R. S., Begeny, C. T., Boyle, P. A., Schneider, J. A., & Bennett, D. A. (2011).

lP

Vulnerability to stress, anxiety, and development of dementia in old age. The American Journal of Geriatric Psychiatry, 19, 327-334.

Wisocki, P., Handen, B., & Morese, C. K. (1986). The worry scale as a measure of anxiety

na

among homebound and community active elderly. Behavior Therapist, 5, 91-95. Wong, S. T., Yoo, G. J., & Steward, A. L. (2006). The changing meaning of family support

ur

among older Chinese and Korean immigrants. Journal of Gerontology: Social Sciences, 61B, S4-S9.

Jo

World Health Organization (2017). Global Health Observatory Data Repository. Retrieved from https://www.who.int/gho/mortality_burden_disease.

Wu, B., Chi, I., Plassman, B. L., & Guo, M. (2010).

Depressive symptoms and health

problems among Chinese immigrant elders in the U.S. and Chinese elders in China. Aging and Mental Health, 14(6), 695-704. Wu, S., Wang R., Zha Y., Ma, X., Wu, M., Yan, X., .... He J. 2013. The relationship between 37

self-rated health and objective health: a population-basd study. BMC Public Health, 13: 320. doi: 10.1186/1471-2458-13-320 Wu, Y., Braun, K., Onaka, A. T., Horiuchi, B. Y., Tottori, C. J., & Wilkens, L. (2017). Life expectancies in Hawai‘i: a multi-ethnic analysis of 2010 life tables. Hawaiian Journal of Medicine and Public Health, 76(1), 9-14. PMCID: PMC5226016. Yamada, C., Moriyama, K., & Takahashi, E. (2015) Self-rated health as a comprehensive indicator of lifestyle-related health status. Environmental Health and Preventive

ro of

Medicine, 17(6), 457-462. doi: 10.1007/s12199-012-0274-x Yi, J. P., Vitaliano, P. P., Smith, R. E., Yi, J. C., & Weinger, K. (2008). The role of resilience on psychological adjustment and health status in patients with diabetes. British journal

-p

of health psychology, 13(Pt 2), 311–325. doi: 10.1348/135910707X186994

Zajacova, A., & Dowd, J. B. (2011). Reliability of self-rated health in US adults. American

re

Journal of Epidemiology, 174(8), 977–983. doi: 10.1093/aje/kwr204

lP

Zhang, J & Wang, Z. 2008. Factors associated with smoking in Asian American adults: a systematic review. Nicotine & Tobacco Research, 10(5): 791-801. Zhang, J., & Wu, L. (2015). Cigarette smoking and alcohol consumption among Chinese

na

older adults: do living arrangements matter? International Jounral of Environmental Research & Public Health, 12(3): 2411-2436.

ur

Zhang, W., Chen, H., & Feng, Q. (2015). Education and psychological distress of older

Jo

Chinese: exploring the longitudinal relationship and its subgroup variations. Journal of Aging and Health, 27, 1170-1198.

Zhang, W., Lacanienta, J., Liu, S., & Wu, B. (2018). Successful ageing: perceptions from elderly Chinese in Hawaii. China Journal of Social Work, 11(3), 236-245.

38

Zhang, W., Liu, S., Zhang, K., & Wu, B. (2019). Neighborhood social cohesion, resilience, and psychological well-being among Chinese older adults in Hawaii. The

Jo

ur

na

lP

re

-p

ro of

Gerontologist, ,gnz 2014. doi: 10.1093/geront/gnz104

39