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Social readjustment and illness patterns: Comparisons between first, second and third generation Italian-Americans living in the same community
Journal of Psychosomatic Research, Vol. 16, pp. 387 to 394. Pergamon Press, 1972. Printed in Great Britain
SOCIAL READJUSTMENT AND ILLNESS PATTERNS: COMPARISONS BETWEEN FIRST, SECOND AND THIRD GENERATION ITALIAN-AMERICANS LIVING IN THE SAME COMMUNITY JOHN G. BRUHN,* BILLY U. PHILIPS* and STEWART WOLF~" (Received 25 April 1972)
HOLMES' quantitative instrument for studying the association between the clustering o f life events and illness onset has been applied to various diagnostic and cultural groups [1-9]. The scale has been shown to have a high degree o f recall validity and to be a valid predictor o f illness onset [10]. Holmes Social Readjustment Rating Questionnaire (SRRQ) was felt to be especially relevant in further elucidating the association between life events and illness onset in an Italian-American community, Roseto, Pennsylvania. This c o m m u n i t y has been the focus of clinical and sociological studies since 1962 in an effort to seek explanations for the c o m m u n i t y ' s low death rate f r o m myocardial infarction [11, 12]. Studies also showed that the c o m m u n i t y had a low incidence o f treated mental illness o f all types [13]. A house-to-house sociological survey o f 86 per cent o f the adult residents o f Roseto, carried out in 1966, provided baseline data regarding social conditions, life styles, values and attitudes [14]. These data could be c o m p a r e d with subsequent data in order to d o c u m e n t the processes o f c o m m u n i t y change and the effects o f change on the health o f the residents. The present paper is a follow-up o f our earlier studies and focuses on life change in the c o m m u n i t y and a m o n g family groups. The purpose o f the study was threefold: (1) to ascertain what differences, if any, existed in the Life Change Unit (LCU) scores a m o n g first, second and third generation Italian-Americans living in the same c o m m u n i t y ; (2) to determine the degree o f association between L C U scores and illness experience a m o n g these three groups; and (3) to gain insight into the possible association between the types and degree o f life change occurring in the c o m m u n i t y since the sociological survey was undertaken five years previously. METHOD The social readjustment rating questionnaire The SRRQ and the method for its administration has been described in detail elsewhere [1]. In summary, it is a self-administered questionnaire comprised of 43 life events derived from clinical experience. Subjects are asked to indicate the number of times each of these events have occurred in their lives during the last six months, six months to one year, one year to two years and two to three years. The number of marks for each item are tabulated, multiplied by the value of the item as reported by Holmes [1], and then summed to obtain the subject's total life change units. A face sheet provides information regarding the subject's age, sex, marital status, religion, education, occupation and other social data. In the present study, in addition to the above, each subject was
*From the Department of Human Ecology, College of Health, University of Oklahoma Health Sciences Center, P.O. Box 26901, Oklahoma City, Oklahoma 73190, and "~The Marine Biomedical Institute, University of Texas Medical Branch, Galveston, Texas 77550. This project was supported by Grant No. MH 20400-01, National Institute of Mental Health, U.S. Public Health Service. 387
388
JOHN G. BRUHN, BILLY U. PHILIPS and STEWART WOLF
asked to list all illnesses (minor and major) which occurred during each of the four time intervals and indicate whether or not he consulted a physician for these illnesses. If the subject saw a physician the physician's name was requested in order that the visit could be validated.
Subjects The subjects were 204 Italian-Americans living in Roseto, Pennsylvania in 1971. Subjects were the adult members of 18 families or "clans" which were selected for study because they were the largest family groups in the community and, in addition, provided a cross-section of first, second and third generation family life. The subjects were visited in their homes by one of four members of our research team who administered the SRRQ. The social characteristics of the total sample are shown in Table 1. The majority of the subjects were second and third generation Italian-Americans who had lived in Roseto for most or all of their lives. The majority of the subjects were Roman Catholic, married, had completed grade or high school and were engaged in skilled or unskilled occupations. The subjects in the sample were representative of the community with respect to these characteristics as determined by the previous sociological survey.
TABLE 1.--SOCIAL CHARACTERISTICSO17 TOTAL SAMPLE
Social characteristic 1. Sex Males Females 2. Mean Age = 54 (range 23-93) 3. Religion Protestants Catholics 4. Marital Status Married Never married Widowed Divorced or separated 5. Education (completed) Grade school High school Technical school College 6. Occupation Professional or managerial Sales and service Clerical Skilled Unskilled Retired 7. Length of residence in community One year Two years Five years Ten years Over ten years 8. Generation First generation (subject and both parents born in Italy) Second generation (Subject born in U.S., both parents born in Italy) Mixed (Subject born in U.S., one parent born in Italy, the other in U.S.) Third generation (Subject born in U.S., both parents born in U.S.)
Frequency 94 110
46 54
41 163
20 80
171 19 14 0
84 9 7 0
96 82 6 20
47 40 3 10
35 12 4 92 13 48
15 6 2 46 8 23
5 7 16 9 167
2 3 8 4 82
13
7
117
57
25
12
49
24
Social readjustment and illness patterns
389
Definitions F o u r generational groups were identified for the purposes of the present study. Subjects who were born in Italy and whose parents were also born in Italy were included in the first generational group. Subjects who were born in the United States, but whose parents were born in Italy were included in the second generational group. Subjects who were born in the United States and had one parent born in Italy and the other parent born in the United States were considered a " m i x e d " generational group. Subjects who were born in the United States and whose parents were also born in the United States comprised the third generational group. RESULTS
Total L C U scores by social variables The generational groups, as would be expected, differed with respect to age; the m e a n age of the first generation was 73 yr, the second generation 57 yr, the "mixed" group 52 yr and the third generation 41 yr. A Pearson Product M o m e n t correlation was computed and it was found that age was significantly negatively correlated with L C U (r = -0.37, p < 0.001), i.e. the lower the age the higher the L C U score. M a n n - W h i t n e y U tests were performed to see if sex, religion and education were related to L C U , but none of these comparisons were statistically significant. The Kruskal-Wallis H test was used to determine the association between occupational groups and L C U , but was not statistically significant. Since 84 per cent of the sample was married no correlations were made between marital status and LCU.
Total L C U scores by generation Figure 1 shows the cumulative percentage distribution of L C U scores by generational group. W h e n the L C U scores of these groups were compared using the M a n n - W h i t n e y U test it was found that the first generation differed significantly from each of the other three groups. The L C U scores of the second generation differed significantly from those of the third generation. However, the L C U scores of the second and third generation did not differ significantly from the "mixed" group. The m e a n L C U scores were 161 for the first generation, 253 for the second, 277 for the "mixed" and 344 for the third.
100
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200
300
, 400
500
r 600
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10JO0
LIFE CHANGE UNIT SCORES
FIG. l . - - C u m u l a t i v e percentage distribution of life change scores by generational groups.
Frequency and magnitude of life changes in sample Table 2 shows the frequency distribution of the total sample on each of the 43 life events. Vacation was the most frequently reported life change followed by death of a close family member or close friend. Six life events were not reported, i.e. jail term, divorce, marital reconciliation, marital separation, fired at work and foreclosure of a mortgage or loan. The reported frequency of life events is in accord with the cultural n o r m s of Roseto. It is a small community of predominately Italians who
390
JOHN G . BRUHN, BILLY O . PHILIPS a n d STEWART WOLF
TABLE 2 . - - M A G N I T U D E AND FREQUENCY OF LIFE CHANGE IN TOTAL SAMPLE AND BY GENERATION
F re que nc y Life change Vacation D e a t h of a close family m e m b e r D e a t h of a close friend Personal injury or illness C h a n g e in health of a family member C h a n g e in financial state G a i n of new family m e m b e r C h a n g e in sleeping habits C h a n g e in eating habits C h a n g e in w o r k h our s or co nditions C h a n g e in church activities O u t s t a n d i n g personal achievement Changes in social activities C h a n g e in responsibilities at work C h a n g e in recreation Son o r d a u g h t e r leaving h o m e Wife began or stopped w o r k C h a n g e in living conditions C h a n g e in n u m b e r of family get-togethers Business r e a d j u s t m e n t C h a n g e in residence M o r t g a g e or loan less than $10,000 Retirement C h a n g e to different line of work Revisio n of p ersonal habits Sex difficulties M i n o r violations of the law T r o u b l e with boss C h a n g e in n u m b e r of a r g u m e n t s with spouse Pregnancy T r o u b l e with in-laws D e a t h of spouse M o r t g a g e over $10,000 Begin or end school Marriage C h a n g e in schools Jail term Divorce M a r i t a l sep aratio n Fired at w o r k Foreclo su re of m o r t g a g e or loan M a r i t a l reconciliation
Magnitude
Total sample
First gen.
Second gen.
"Mixed" gen.
Third gen.
13 63 37 53
593 158 120 87
18 l0 2 6
340 99 80 49
73 19 10 5
162 30 28 27
44 38 39 16 15
85 85 74 60 54
3 --2 4
38 43 28 27 30
11 7 11 13 5
33 35 35 18 15
20 19
52 50
3 --
32 27
5 9
12 14
28 18
50 49
1 --
34 30
5 2
10 17
29 19 29 26 25
47 46 46 42 38
------
21 19 29 28 20
8 6 7 1 6
18 21 10 13 12
15 39 20
36 27 23
----
17 10 8
8 3 10
11 14 5
17 45
23 17
-2
5 14
4 1
14 --
36 24 39 11 23
17 14 14 13 12
1 -----
6 5 12 7 5
2 5 1 -2
8 4 I 6 5
35 40 29 100 31 26 50 20 63 73 65 47
11 10 6 9 6 8 2 2
---4 -----
6 1 1 4
1 2 --1 2 ---
4 7 5 1 5 5 2 2
. . . .
30 45
. .
--
. . . . .
. . . . .
.
1 --. . . . .
.
. . . . .
.
. .
are largely R o m a n C a t h o l i c a n d who have lived in the c o m m u n i t y m o s t of their lives. The comm u n i t y has r e m a i n e d r e m a r k a b l y stable, n o t h a v i n g experienced a n influx of I t a l i a n s from I t a l y
Social readjustment and illness patterns
391
since the early 1900's. Its culture has been modified by the values of larger American society primarily through Rosetans working in nearby towns and young Rosetans attending college. While industrious, Rosetans take time for annual vacations, in fact, the mills which employ a majority of Rosetan women as sewing machine operators close for bi-annual vacations. A high degree of family and community solidarity prevails, hence deaths occurring in the community have a marked impact, this is especially so when the death of an older member occurs signalling the decreasing influence of Old World ways in the life of the community. The prevailing religion is R o m a n Catholic, thus accounting for the lack of divorce, marital separation or marital reconciliation as life events of consequence. Pride in economic self-sufficiency and rallying to aid those in financial distress accounts for the lack of foreclosure of a mortgage or loan as a major life event. Respect for family and community norms necessitates only a token police force and an inactive jail. Therefore, the majority of life changes reported are largely those involving personal habits.
Life change categories by generation When the 43 life events were grouped in a manner similar to that used by Rahe [7] it was found that the generational groups differed significantly according to the categories of reported life events (Table 3). Significantly more of the first and "mixed" generational subjects than expected reported familial life changes, more second generational subjects reported personal life changes and more third generational subjects reported changes in the area of work and finance (Z 2 = 177.30; 6 df; p < 0.001). TABLE 3.--FREQUENCY OF LIFE CHANGE CATEGORIES BY GENERATION
Generation Life change categories*
First
Second
N--
%
N=
%
17 33 6 56
30 59 11 100
250 691 136 1077
23 64 13 100
Family Personal Work and Finance Total no. changes
"Mixed"
N= 152 59 33 244
% 62 24 14 100
Third
N=
%
147 347 111 605
24 57 18 99
* Z 2 = 177'30; 6 df;p < 0"001.
Total LCU scores by illness experience
Subjects were grouped into two categories, those reporting illnesses and those who did not. The Mann-Whitney U test was used to assess the relationship between LCU scores and illness and was statistically significant (U = 3947, p < 0'01). The group of subjects reporting illnesses had higher L C U scores than those subjects reporting no illnesses. Frequency and type of illness by generation Table 4 shows the frequency distribution of illness by generation. The majority (77 per cent) of the first generation reported no illnesses over the three year period covered by the SRRQ. Approximately half of the second and third generation reported no illnesses and one-third of the "mixed" generation reported no illnesses. It is especially interesting that very few individuals in all generations reported more than one illness during the three year period. Table 5 shows the distribution of illness categories by generation for those individuals who reported illnesses. Since only four individuals in the first generation reported illnesses the sample size does not warrant inferences about illness type. However, it is of interest that the majority of individuals in the second, "mixed" and third generation groups reported gastro-intestinal, musculoskeletal, respiratory and genito-urinary illnesses. Sixteen per cent of the second generation reported cardiovascular illnesses, while none were reported among the "mixed" generational group and only six per cent were reported among the third generation. The high frequency of physician visits among all four generational groups is of particular interest. Undoubtedly the accessibility of Italian physicians within one mile of Roseto is a factor in the high utilization. Also, the fact that the community has been under study by our group since 1962 has modified the community's views toward illness, especially heart disease, and may account for the greater utilization of physicians.
392
JOHN G. BRUHN, BILLY U. PHILIPS a n d STEWARI WOLF TABLE 4.--FREQUENCY OF ILLNESS BY GENERATION Generation N u m b e r of illnesses per person
First N-- %
None
10
I
2
2 3 4_
1
77 15 8
13
100
Totals
Second N= %
55 42 14 5 1 117
47 36 12 4 1 100
"Mixed" N---: %
Third N-- %
8 16 1
32 64 4
24 18 6 1
49
25
100
49
100
37
12 2
TABLE 5.--FREQUENCY OF ILLNESS TYPE BY GENERATION Generation Illness category
Dermatological Respiratory Gastro-intestinal Musculoskeletal Cranial Cardiovascular Genito-urinary Neuropsychiatric General Totals T h o s e sick who consulted a physician
First N %
Second N-- %
1 1
25 25
1
25
1 4
25 100
5 6 15 16 7 15 7 3 18 92
4
100
85
5 7 16 17 8 16 8 3 20 100
92
"Mixed" N= % 1 3 7 2 2
6 17 39 11 11
1
6
2 18
17
Third N= %
11 100
3 5 5 8 2 2 5 1 2 33
9 15 15 24 6 6 15 3 6 100
94
32
97
Life change hi Roseto in h&torical perspective T h e historical evolution of R o s e t o a n d descriptions of the early life of its inhabitants h a s been well d o c u m e n t e d [16, 17]. In addition, a description of the way o f life o f the c o m m u n i t y as we f o u n d it in 1962 h a s been reported [11]. R o s e t o is m a r k e d l y different f r o m other Italian settlements in large A m e r i c a n cities [17]. R o s e t a n s share a c o m m o n ancestry which, in the past, h a s b o u n d t h e m to relatives a n d friends in Roseto, Valfortore in the Province of Foggia, Italy. Like other i m m i g r a n t s a r o u n d the turn of the 19th century a small g r o u p of R o s e t a n s c a m e to A m e r i c a in search o f f r e e d o m f r o m feudal lords a n d poverty. Roseto h a s m a i n t a i n e d itself as a separate ethnic enclave c o m p o s e d almost entirely of Italians since 1912, a n d h a s admitted only non-Italians w h o have married Italians into the c o m m u n i t y . I m m i g r a n t s f r o m Roseto, a n d other parts o f Italy have settled in T o r o n t o , C a n a d a since that time. While Roseto, Pennsylvania h a s lost m a n y y o u n g residents to the m a i n s t r e a m o f A m e r i c a n society t h r o u g h inter-ethnic marriage a n d better jobs, it h a s been able to retain its exclusivity since incorporation as a separate municipal b o r o u g h . R o s e t a n s have been able to retain m a n y of the Old W o r l d ways which are closely tied to religion a n d the extended family. W e noted in 1962, however, that R o s e t o was rapidly u n d e r g o i n g acculturation as y o u n g R o s e t a n s went to school in a nearby non-Italian c o m m u n i t y . M a n y y o u n g m e n went a w a y to college, or worked outside the c o m m u n i t y . Also, as R o s e t a n s have become m o r e affluent they have increasingly s o u g h t the pleasures o f material goods a n d leisure activities offered outside the c o m m u n i t y . By 1965 the social clubs in Roseto b e g a n to decline in m e m b e r s h i p . Inter-ethnic a n d inter-religious marriages increased. T h e birth rate b e g a n to decline. R o s e t a n s began building fashionable h o m e s outside the b o r o u g h b o u n d a r y a n d s o m e attended churches outside the c o m m u n i t y . Since 1966, w h e n the h o u s e - t o - h o u s e sociological survey was conducted, there h a s been a notable increase in the n u m b e r o f R o s e t a n s with s u m m e r h o m e s , s w i m m i n g pools, bars in their h o m e s , b o a t s a n d n e w cars. Dietary habits have c h a n g e d as y o u n g R o s e t a n s eat away f r o m h o m e m o r e frequently a n d w o m e n engage in dieting. R o s e t a n s n o w go to E u r o p e on vacation, to Las Vegas or to the racetrack. T h e c o m m u n i t y initiated
Social readjustment and illness patterns
393
its first Golf Tournament in 1971. In the past year the Presbyterian Churches in Roseto and adjacent Bangor have consolidated. Third and fourth generation Rosetans seldom know the Italian language and perhaps more striking the first two deaths from myocardial infarction among men under the age of 45 were recorded in 1971. it is in this setting of accelerating social and cultural change that the present study was conducted in 1971 to ascertain the degree to which the Holmes Social Readjustment Scale would shed light on life changes and illness experienced among the different generational groups living in the community. As the first generation die the last remaining ties of the community to the Old World are rapidly disappearing and the community is fast becoming indistinguishable in habits, customs, folkways and language from larger American society. DISCUSSION The findings that L C U scores were highest among third generation Rosetans, who were also younger, would be expected if the number and type of life change is related to age and acculturation. Indeed, third generation Rosetans reported more life changes related to work and finance, the second generation had more changes in their personal lives and the first and "mixed" generation reported more life changes related to family life. Vacation and death were the two most frequently reported life changes across generational groups. Death has been the most prevalent life change reported in other cultural groups [5-7], but vacation has ranked toward the bottom in these groups when the frequency of the 43 life events are ordered. This difference is undoubtedly due to the fact that vacations are an important event in the community of Roseto. Work for those employed in the community is suspended for two weeks twice each year and the impact of this is evidenced by the marked decrease in the social activities of the town during these periods. The obvious omission of divorce, separation and reconciliation as life changes is related to the Roman Catholic religious norms which guide the lives of 75 per cent of Rosetans. Illness experience was significantly related to LCU. However, 77 per cent of the first generation reported no illnesses over a three year period. It should be pointed out, however, that first generation Rosetans are no doubt a select group. The fact that they are living beyond the usual life expectancy for most Americans and report few health problems attests to their physical stamina. It is of interest that 16 per cent of the second generation which is a high risk age group for cardiovascular disease reported such illnesses. Since the prevalence of cardiovascular disease in the community has been of special interest in our studies, the continuation of follow-up studies among second and third generation Rosetans will further elucidate the relationship between changes in the rate of cardiovascular disease and the processes of social change and acculturation in the community. SUMMARY After about 80 yr as a fairly stable society Roseto, over the past seven to ten years, has been undergoing a rapid acculturation into the conventional American pattern. Formerly close family and community ties have been weakened and the selfcontained, self-sufficient character of the society has been eroded as the oldest inhabitants have died and the youngsters of ten years ago have come into a position of social influence. To document the changes as they have affected individuals, the Holmes Social Readjustment Rating Questionnaire was given to 204 Italian-Americans living in Roseto, Pennsylvania to ascertain what differences, if any, existed in the Life Change Unit scores of first, second and third generation groups and to determine
394
JOHN G. BRUHN, BILLY U. PHILIPS and STEWART WOLF
the degree o f association between L C U scores an d illness experience in these three groups. Th e L C U scores were f o u n d to increase with acculturation, i.e. the first generation h a d the lowest a n d the third generation h ad the highest L C U scores. The generational groups also differed with respect to the type o f life change they experienced. Th e first generation reported m o r e changes in family life, the second generation experienced m o r e change in their personal lives and third generation reported m o r e changes with respect to w o r k and financial matters. L C U was f o u n d to be significantly related to illness experience. The m a j o r i t y o f the first generation reported no illnesses, while the second a n d third generation were m o r e similar than different in b o t h the n u m b e r and types o f illness experienced. Th e results were discussed in terms o f the social a n d cultural changes that have occurred in the comm u n i t y during the past ten years it has been undergoing study by o u r group. Acknowledgement--We are grateful to Robert Bowser, Jim Goldsberry, and Kay'da Grace who
assisted in data collection.
REFERENCES 1. HOLMEST. H. and RAHE R. H. The social readjustment rating scale. J. Psychosom. Res. l l , 213 (1967). 2. RAHER. H., MEYERM., SMITHM., KJAERG. and HOLMEST. H. Social stress and illness onset. J. Psychosom. Res. 8, 35 (1964). 3. CASEYR. L., MASUDAM. and HOLMEST. H. Quantitative study of recall of life events. J. Psychosom. Res. 11, 239 (1967). 4. HOLMEST. S. and HOLMEST. H. Short-term intrusions into the life style routine. J. Psychosom. Res. 14, 121 (1970). 5. MASUDAM. and HOLMEST. H. The social readjustment rating scale: a cross-cultural study of Japanese and Americans. J. Psychosom. Res. 11, 227 (1967). 6. HARMOND. K., MASUDAM. and HOLMEST. H. The social readjustment rating scale: a crosscultural study of Western Europeans and Americans. J. Psychosom. Res. 14, 391 (1970). 7. RAHER. H., LUNDBERGU., BENNETTL. and THEORELLT. The social readjustment rating scale: a comparative study of Swedes and Americans. J. Psychosom. Res. 15, 241 (1971). 8. KOMAROFEA. L., MASUDAM. and HOLMEST. H. The social readjustment rating scale: a comparative study of Negro, Mexican and White Americans. J. Psychosom. Res. 12, 121 (1968). 9. PAYKELE. S., PRUSOEFB. A. and UHLENHUTHE. H. Scaling of life events. Archs. Gen. Psychiat. 25, 340 (1971). 10. RAHE R. H. Life-change measurement as a predictor of illness. Proc. R. Soc. Med. 61, 1124 (1968). 11. BRUNN J. G. An epidemiological study of myocardial infarctions in an Italian-American community: a preliminary sociological study. J. Chron. Dis. 18, 353 0965). 12. BRUHNJ. G., CHANDLERB. C., MILLERM. C., WOLF S. and LYNN T. N. Social aspects of coronary heart disease in two adjacent ethnically different communities. Am. J. Pub. Hlth. 56, 1493 (1966). 13. BRUHN J. G., BRANDT E. N. and SHACKELFORDM. Incidence of treated mental illness in three Pennsylvania communities. Am. J. Pub. Hlth. 56, 871 (1966). 14. BRUHNJ. G. Sociological factors related to participation in a screening clinic for heart disease Soc. Sci. & Med. 3, 85 (1969). 15. BASSOR. History of Roseto, Pa. : 1882-1952. Tanzella, Easton, Pa. (1952). 16. FACCHIANOA. Roseto Valfortore. Tipografia Casa Sacro Cuore S. Agata di Puglia (Foggia), (1970). 17. GANSH. J. The Urban Villagers. Free Press, Glencoe, Ill. (1962).
SOCIAL READJUSTMENT AND ILLNESS PATTERNS: COMPARISONS BETWEEN FIRST, SECOND AND THIRD GENERATION ITALIAN-AMERICANS LIVING IN THE SAME COMMUNITY JOHN G. BRUHN,* BILLY U. PHILIPS* and STEWART WOLF~" (Received 25 April 1972)
HOLMES' quantitative instrument for studying the association between the clustering o f life events and illness onset has been applied to various diagnostic and cultural groups [1-9]. The scale has been shown to have a high degree o f recall validity and to be a valid predictor o f illness onset [10]. Holmes Social Readjustment Rating Questionnaire (SRRQ) was felt to be especially relevant in further elucidating the association between life events and illness onset in an Italian-American community, Roseto, Pennsylvania. This c o m m u n i t y has been the focus of clinical and sociological studies since 1962 in an effort to seek explanations for the c o m m u n i t y ' s low death rate f r o m myocardial infarction [11, 12]. Studies also showed that the c o m m u n i t y had a low incidence o f treated mental illness o f all types [13]. A house-to-house sociological survey o f 86 per cent o f the adult residents o f Roseto, carried out in 1966, provided baseline data regarding social conditions, life styles, values and attitudes [14]. These data could be c o m p a r e d with subsequent data in order to d o c u m e n t the processes o f c o m m u n i t y change and the effects o f change on the health o f the residents. The present paper is a follow-up o f our earlier studies and focuses on life change in the c o m m u n i t y and a m o n g family groups. The purpose o f the study was threefold: (1) to ascertain what differences, if any, existed in the Life Change Unit (LCU) scores a m o n g first, second and third generation Italian-Americans living in the same c o m m u n i t y ; (2) to determine the degree o f association between L C U scores and illness experience a m o n g these three groups; and (3) to gain insight into the possible association between the types and degree o f life change occurring in the c o m m u n i t y since the sociological survey was undertaken five years previously. METHOD The social readjustment rating questionnaire The SRRQ and the method for its administration has been described in detail elsewhere [1]. In summary, it is a self-administered questionnaire comprised of 43 life events derived from clinical experience. Subjects are asked to indicate the number of times each of these events have occurred in their lives during the last six months, six months to one year, one year to two years and two to three years. The number of marks for each item are tabulated, multiplied by the value of the item as reported by Holmes [1], and then summed to obtain the subject's total life change units. A face sheet provides information regarding the subject's age, sex, marital status, religion, education, occupation and other social data. In the present study, in addition to the above, each subject was
*From the Department of Human Ecology, College of Health, University of Oklahoma Health Sciences Center, P.O. Box 26901, Oklahoma City, Oklahoma 73190, and "~The Marine Biomedical Institute, University of Texas Medical Branch, Galveston, Texas 77550. This project was supported by Grant No. MH 20400-01, National Institute of Mental Health, U.S. Public Health Service. 387
388
JOHN G. BRUHN, BILLY U. PHILIPS and STEWART WOLF
asked to list all illnesses (minor and major) which occurred during each of the four time intervals and indicate whether or not he consulted a physician for these illnesses. If the subject saw a physician the physician's name was requested in order that the visit could be validated.
Subjects The subjects were 204 Italian-Americans living in Roseto, Pennsylvania in 1971. Subjects were the adult members of 18 families or "clans" which were selected for study because they were the largest family groups in the community and, in addition, provided a cross-section of first, second and third generation family life. The subjects were visited in their homes by one of four members of our research team who administered the SRRQ. The social characteristics of the total sample are shown in Table 1. The majority of the subjects were second and third generation Italian-Americans who had lived in Roseto for most or all of their lives. The majority of the subjects were Roman Catholic, married, had completed grade or high school and were engaged in skilled or unskilled occupations. The subjects in the sample were representative of the community with respect to these characteristics as determined by the previous sociological survey.
TABLE 1.--SOCIAL CHARACTERISTICSO17 TOTAL SAMPLE
Social characteristic 1. Sex Males Females 2. Mean Age = 54 (range 23-93) 3. Religion Protestants Catholics 4. Marital Status Married Never married Widowed Divorced or separated 5. Education (completed) Grade school High school Technical school College 6. Occupation Professional or managerial Sales and service Clerical Skilled Unskilled Retired 7. Length of residence in community One year Two years Five years Ten years Over ten years 8. Generation First generation (subject and both parents born in Italy) Second generation (Subject born in U.S., both parents born in Italy) Mixed (Subject born in U.S., one parent born in Italy, the other in U.S.) Third generation (Subject born in U.S., both parents born in U.S.)
Frequency 94 110
46 54
41 163
20 80
171 19 14 0
84 9 7 0
96 82 6 20
47 40 3 10
35 12 4 92 13 48
15 6 2 46 8 23
5 7 16 9 167
2 3 8 4 82
13
7
117
57
25
12
49
24
Social readjustment and illness patterns
389
Definitions F o u r generational groups were identified for the purposes of the present study. Subjects who were born in Italy and whose parents were also born in Italy were included in the first generational group. Subjects who were born in the United States, but whose parents were born in Italy were included in the second generational group. Subjects who were born in the United States and had one parent born in Italy and the other parent born in the United States were considered a " m i x e d " generational group. Subjects who were born in the United States and whose parents were also born in the United States comprised the third generational group. RESULTS
Total L C U scores by social variables The generational groups, as would be expected, differed with respect to age; the m e a n age of the first generation was 73 yr, the second generation 57 yr, the "mixed" group 52 yr and the third generation 41 yr. A Pearson Product M o m e n t correlation was computed and it was found that age was significantly negatively correlated with L C U (r = -0.37, p < 0.001), i.e. the lower the age the higher the L C U score. M a n n - W h i t n e y U tests were performed to see if sex, religion and education were related to L C U , but none of these comparisons were statistically significant. The Kruskal-Wallis H test was used to determine the association between occupational groups and L C U , but was not statistically significant. Since 84 per cent of the sample was married no correlations were made between marital status and LCU.
Total L C U scores by generation Figure 1 shows the cumulative percentage distribution of L C U scores by generational group. W h e n the L C U scores of these groups were compared using the M a n n - W h i t n e y U test it was found that the first generation differed significantly from each of the other three groups. The L C U scores of the second generation differed significantly from those of the third generation. However, the L C U scores of the second and third generation did not differ significantly from the "mixed" group. The m e a n L C U scores were 161 for the first generation, 253 for the second, 277 for the "mixed" and 344 for the third.
100
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200
300
, 400
500
r 600
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' 900
10JO0
LIFE CHANGE UNIT SCORES
FIG. l . - - C u m u l a t i v e percentage distribution of life change scores by generational groups.
Frequency and magnitude of life changes in sample Table 2 shows the frequency distribution of the total sample on each of the 43 life events. Vacation was the most frequently reported life change followed by death of a close family member or close friend. Six life events were not reported, i.e. jail term, divorce, marital reconciliation, marital separation, fired at work and foreclosure of a mortgage or loan. The reported frequency of life events is in accord with the cultural n o r m s of Roseto. It is a small community of predominately Italians who
390
JOHN G . BRUHN, BILLY O . PHILIPS a n d STEWART WOLF
TABLE 2 . - - M A G N I T U D E AND FREQUENCY OF LIFE CHANGE IN TOTAL SAMPLE AND BY GENERATION
F re que nc y Life change Vacation D e a t h of a close family m e m b e r D e a t h of a close friend Personal injury or illness C h a n g e in health of a family member C h a n g e in financial state G a i n of new family m e m b e r C h a n g e in sleeping habits C h a n g e in eating habits C h a n g e in w o r k h our s or co nditions C h a n g e in church activities O u t s t a n d i n g personal achievement Changes in social activities C h a n g e in responsibilities at work C h a n g e in recreation Son o r d a u g h t e r leaving h o m e Wife began or stopped w o r k C h a n g e in living conditions C h a n g e in n u m b e r of family get-togethers Business r e a d j u s t m e n t C h a n g e in residence M o r t g a g e or loan less than $10,000 Retirement C h a n g e to different line of work Revisio n of p ersonal habits Sex difficulties M i n o r violations of the law T r o u b l e with boss C h a n g e in n u m b e r of a r g u m e n t s with spouse Pregnancy T r o u b l e with in-laws D e a t h of spouse M o r t g a g e over $10,000 Begin or end school Marriage C h a n g e in schools Jail term Divorce M a r i t a l sep aratio n Fired at w o r k Foreclo su re of m o r t g a g e or loan M a r i t a l reconciliation
Magnitude
Total sample
First gen.
Second gen.
"Mixed" gen.
Third gen.
13 63 37 53
593 158 120 87
18 l0 2 6
340 99 80 49
73 19 10 5
162 30 28 27
44 38 39 16 15
85 85 74 60 54
3 --2 4
38 43 28 27 30
11 7 11 13 5
33 35 35 18 15
20 19
52 50
3 --
32 27
5 9
12 14
28 18
50 49
1 --
34 30
5 2
10 17
29 19 29 26 25
47 46 46 42 38
------
21 19 29 28 20
8 6 7 1 6
18 21 10 13 12
15 39 20
36 27 23
----
17 10 8
8 3 10
11 14 5
17 45
23 17
-2
5 14
4 1
14 --
36 24 39 11 23
17 14 14 13 12
1 -----
6 5 12 7 5
2 5 1 -2
8 4 I 6 5
35 40 29 100 31 26 50 20 63 73 65 47
11 10 6 9 6 8 2 2
---4 -----
6 1 1 4
1 2 --1 2 ---
4 7 5 1 5 5 2 2
. . . .
30 45
. .
--
. . . . .
. . . . .
.
1 --. . . . .
.
. . . . .
.
. .
are largely R o m a n C a t h o l i c a n d who have lived in the c o m m u n i t y m o s t of their lives. The comm u n i t y has r e m a i n e d r e m a r k a b l y stable, n o t h a v i n g experienced a n influx of I t a l i a n s from I t a l y
Social readjustment and illness patterns
391
since the early 1900's. Its culture has been modified by the values of larger American society primarily through Rosetans working in nearby towns and young Rosetans attending college. While industrious, Rosetans take time for annual vacations, in fact, the mills which employ a majority of Rosetan women as sewing machine operators close for bi-annual vacations. A high degree of family and community solidarity prevails, hence deaths occurring in the community have a marked impact, this is especially so when the death of an older member occurs signalling the decreasing influence of Old World ways in the life of the community. The prevailing religion is R o m a n Catholic, thus accounting for the lack of divorce, marital separation or marital reconciliation as life events of consequence. Pride in economic self-sufficiency and rallying to aid those in financial distress accounts for the lack of foreclosure of a mortgage or loan as a major life event. Respect for family and community norms necessitates only a token police force and an inactive jail. Therefore, the majority of life changes reported are largely those involving personal habits.
Life change categories by generation When the 43 life events were grouped in a manner similar to that used by Rahe [7] it was found that the generational groups differed significantly according to the categories of reported life events (Table 3). Significantly more of the first and "mixed" generational subjects than expected reported familial life changes, more second generational subjects reported personal life changes and more third generational subjects reported changes in the area of work and finance (Z 2 = 177.30; 6 df; p < 0.001). TABLE 3.--FREQUENCY OF LIFE CHANGE CATEGORIES BY GENERATION
Generation Life change categories*
First
Second
N--
%
N=
%
17 33 6 56
30 59 11 100
250 691 136 1077
23 64 13 100
Family Personal Work and Finance Total no. changes
"Mixed"
N= 152 59 33 244
% 62 24 14 100
Third
N=
%
147 347 111 605
24 57 18 99
* Z 2 = 177'30; 6 df;p < 0"001.
Total LCU scores by illness experience
Subjects were grouped into two categories, those reporting illnesses and those who did not. The Mann-Whitney U test was used to assess the relationship between LCU scores and illness and was statistically significant (U = 3947, p < 0'01). The group of subjects reporting illnesses had higher L C U scores than those subjects reporting no illnesses. Frequency and type of illness by generation Table 4 shows the frequency distribution of illness by generation. The majority (77 per cent) of the first generation reported no illnesses over the three year period covered by the SRRQ. Approximately half of the second and third generation reported no illnesses and one-third of the "mixed" generation reported no illnesses. It is especially interesting that very few individuals in all generations reported more than one illness during the three year period. Table 5 shows the distribution of illness categories by generation for those individuals who reported illnesses. Since only four individuals in the first generation reported illnesses the sample size does not warrant inferences about illness type. However, it is of interest that the majority of individuals in the second, "mixed" and third generation groups reported gastro-intestinal, musculoskeletal, respiratory and genito-urinary illnesses. Sixteen per cent of the second generation reported cardiovascular illnesses, while none were reported among the "mixed" generational group and only six per cent were reported among the third generation. The high frequency of physician visits among all four generational groups is of particular interest. Undoubtedly the accessibility of Italian physicians within one mile of Roseto is a factor in the high utilization. Also, the fact that the community has been under study by our group since 1962 has modified the community's views toward illness, especially heart disease, and may account for the greater utilization of physicians.
392
JOHN G. BRUHN, BILLY U. PHILIPS a n d STEWARI WOLF TABLE 4.--FREQUENCY OF ILLNESS BY GENERATION Generation N u m b e r of illnesses per person
First N-- %
None
10
I
2
2 3 4_
1
77 15 8
13
100
Totals
Second N= %
55 42 14 5 1 117
47 36 12 4 1 100
"Mixed" N---: %
Third N-- %
8 16 1
32 64 4
24 18 6 1
49
25
100
49
100
37
12 2
TABLE 5.--FREQUENCY OF ILLNESS TYPE BY GENERATION Generation Illness category
Dermatological Respiratory Gastro-intestinal Musculoskeletal Cranial Cardiovascular Genito-urinary Neuropsychiatric General Totals T h o s e sick who consulted a physician
First N %
Second N-- %
1 1
25 25
1
25
1 4
25 100
5 6 15 16 7 15 7 3 18 92
4
100
85
5 7 16 17 8 16 8 3 20 100
92
"Mixed" N= % 1 3 7 2 2
6 17 39 11 11
1
6
2 18
17
Third N= %
11 100
3 5 5 8 2 2 5 1 2 33
9 15 15 24 6 6 15 3 6 100
94
32
97
Life change hi Roseto in h&torical perspective T h e historical evolution of R o s e t o a n d descriptions of the early life of its inhabitants h a s been well d o c u m e n t e d [16, 17]. In addition, a description of the way o f life o f the c o m m u n i t y as we f o u n d it in 1962 h a s been reported [11]. R o s e t o is m a r k e d l y different f r o m other Italian settlements in large A m e r i c a n cities [17]. R o s e t a n s share a c o m m o n ancestry which, in the past, h a s b o u n d t h e m to relatives a n d friends in Roseto, Valfortore in the Province of Foggia, Italy. Like other i m m i g r a n t s a r o u n d the turn of the 19th century a small g r o u p of R o s e t a n s c a m e to A m e r i c a in search o f f r e e d o m f r o m feudal lords a n d poverty. Roseto h a s m a i n t a i n e d itself as a separate ethnic enclave c o m p o s e d almost entirely of Italians since 1912, a n d h a s admitted only non-Italians w h o have married Italians into the c o m m u n i t y . I m m i g r a n t s f r o m Roseto, a n d other parts o f Italy have settled in T o r o n t o , C a n a d a since that time. While Roseto, Pennsylvania h a s lost m a n y y o u n g residents to the m a i n s t r e a m o f A m e r i c a n society t h r o u g h inter-ethnic marriage a n d better jobs, it h a s been able to retain its exclusivity since incorporation as a separate municipal b o r o u g h . R o s e t a n s have been able to retain m a n y of the Old W o r l d ways which are closely tied to religion a n d the extended family. W e noted in 1962, however, that R o s e t o was rapidly u n d e r g o i n g acculturation as y o u n g R o s e t a n s went to school in a nearby non-Italian c o m m u n i t y . M a n y y o u n g m e n went a w a y to college, or worked outside the c o m m u n i t y . Also, as R o s e t a n s have become m o r e affluent they have increasingly s o u g h t the pleasures o f material goods a n d leisure activities offered outside the c o m m u n i t y . By 1965 the social clubs in Roseto b e g a n to decline in m e m b e r s h i p . Inter-ethnic a n d inter-religious marriages increased. T h e birth rate b e g a n to decline. R o s e t a n s began building fashionable h o m e s outside the b o r o u g h b o u n d a r y a n d s o m e attended churches outside the c o m m u n i t y . Since 1966, w h e n the h o u s e - t o - h o u s e sociological survey was conducted, there h a s been a notable increase in the n u m b e r o f R o s e t a n s with s u m m e r h o m e s , s w i m m i n g pools, bars in their h o m e s , b o a t s a n d n e w cars. Dietary habits have c h a n g e d as y o u n g R o s e t a n s eat away f r o m h o m e m o r e frequently a n d w o m e n engage in dieting. R o s e t a n s n o w go to E u r o p e on vacation, to Las Vegas or to the racetrack. T h e c o m m u n i t y initiated
Social readjustment and illness patterns
393
its first Golf Tournament in 1971. In the past year the Presbyterian Churches in Roseto and adjacent Bangor have consolidated. Third and fourth generation Rosetans seldom know the Italian language and perhaps more striking the first two deaths from myocardial infarction among men under the age of 45 were recorded in 1971. it is in this setting of accelerating social and cultural change that the present study was conducted in 1971 to ascertain the degree to which the Holmes Social Readjustment Scale would shed light on life changes and illness experienced among the different generational groups living in the community. As the first generation die the last remaining ties of the community to the Old World are rapidly disappearing and the community is fast becoming indistinguishable in habits, customs, folkways and language from larger American society. DISCUSSION The findings that L C U scores were highest among third generation Rosetans, who were also younger, would be expected if the number and type of life change is related to age and acculturation. Indeed, third generation Rosetans reported more life changes related to work and finance, the second generation had more changes in their personal lives and the first and "mixed" generation reported more life changes related to family life. Vacation and death were the two most frequently reported life changes across generational groups. Death has been the most prevalent life change reported in other cultural groups [5-7], but vacation has ranked toward the bottom in these groups when the frequency of the 43 life events are ordered. This difference is undoubtedly due to the fact that vacations are an important event in the community of Roseto. Work for those employed in the community is suspended for two weeks twice each year and the impact of this is evidenced by the marked decrease in the social activities of the town during these periods. The obvious omission of divorce, separation and reconciliation as life changes is related to the Roman Catholic religious norms which guide the lives of 75 per cent of Rosetans. Illness experience was significantly related to LCU. However, 77 per cent of the first generation reported no illnesses over a three year period. It should be pointed out, however, that first generation Rosetans are no doubt a select group. The fact that they are living beyond the usual life expectancy for most Americans and report few health problems attests to their physical stamina. It is of interest that 16 per cent of the second generation which is a high risk age group for cardiovascular disease reported such illnesses. Since the prevalence of cardiovascular disease in the community has been of special interest in our studies, the continuation of follow-up studies among second and third generation Rosetans will further elucidate the relationship between changes in the rate of cardiovascular disease and the processes of social change and acculturation in the community. SUMMARY After about 80 yr as a fairly stable society Roseto, over the past seven to ten years, has been undergoing a rapid acculturation into the conventional American pattern. Formerly close family and community ties have been weakened and the selfcontained, self-sufficient character of the society has been eroded as the oldest inhabitants have died and the youngsters of ten years ago have come into a position of social influence. To document the changes as they have affected individuals, the Holmes Social Readjustment Rating Questionnaire was given to 204 Italian-Americans living in Roseto, Pennsylvania to ascertain what differences, if any, existed in the Life Change Unit scores of first, second and third generation groups and to determine
394
JOHN G. BRUHN, BILLY U. PHILIPS and STEWART WOLF
the degree o f association between L C U scores an d illness experience in these three groups. Th e L C U scores were f o u n d to increase with acculturation, i.e. the first generation h a d the lowest a n d the third generation h ad the highest L C U scores. The generational groups also differed with respect to the type o f life change they experienced. Th e first generation reported m o r e changes in family life, the second generation experienced m o r e change in their personal lives and third generation reported m o r e changes with respect to w o r k and financial matters. L C U was f o u n d to be significantly related to illness experience. The m a j o r i t y o f the first generation reported no illnesses, while the second a n d third generation were m o r e similar than different in b o t h the n u m b e r and types o f illness experienced. Th e results were discussed in terms o f the social a n d cultural changes that have occurred in the comm u n i t y during the past ten years it has been undergoing study by o u r group. Acknowledgement--We are grateful to Robert Bowser, Jim Goldsberry, and Kay'da Grace who
assisted in data collection.
REFERENCES 1. HOLMEST. H. and RAHE R. H. The social readjustment rating scale. J. Psychosom. Res. l l , 213 (1967). 2. RAHER. H., MEYERM., SMITHM., KJAERG. and HOLMEST. H. Social stress and illness onset. J. Psychosom. Res. 8, 35 (1964). 3. CASEYR. L., MASUDAM. and HOLMEST. H. Quantitative study of recall of life events. J. Psychosom. Res. 11, 239 (1967). 4. HOLMEST. S. and HOLMEST. H. Short-term intrusions into the life style routine. J. Psychosom. Res. 14, 121 (1970). 5. MASUDAM. and HOLMEST. H. The social readjustment rating scale: a cross-cultural study of Japanese and Americans. J. Psychosom. Res. 11, 227 (1967). 6. HARMOND. K., MASUDAM. and HOLMEST. H. The social readjustment rating scale: a crosscultural study of Western Europeans and Americans. J. Psychosom. Res. 14, 391 (1970). 7. RAHER. H., LUNDBERGU., BENNETTL. and THEORELLT. The social readjustment rating scale: a comparative study of Swedes and Americans. J. Psychosom. Res. 15, 241 (1971). 8. KOMAROFEA. L., MASUDAM. and HOLMEST. H. The social readjustment rating scale: a comparative study of Negro, Mexican and White Americans. J. Psychosom. Res. 12, 121 (1968). 9. PAYKELE. S., PRUSOEFB. A. and UHLENHUTHE. H. Scaling of life events. Archs. Gen. Psychiat. 25, 340 (1971). 10. RAHE R. H. Life-change measurement as a predictor of illness. Proc. R. Soc. Med. 61, 1124 (1968). 11. BRUNN J. G. An epidemiological study of myocardial infarctions in an Italian-American community: a preliminary sociological study. J. Chron. Dis. 18, 353 0965). 12. BRUHNJ. G., CHANDLERB. C., MILLERM. C., WOLF S. and LYNN T. N. Social aspects of coronary heart disease in two adjacent ethnically different communities. Am. J. Pub. Hlth. 56, 1493 (1966). 13. BRUHN J. G., BRANDT E. N. and SHACKELFORDM. Incidence of treated mental illness in three Pennsylvania communities. Am. J. Pub. Hlth. 56, 871 (1966). 14. BRUHNJ. G. Sociological factors related to participation in a screening clinic for heart disease Soc. Sci. & Med. 3, 85 (1969). 15. BASSOR. History of Roseto, Pa. : 1882-1952. Tanzella, Easton, Pa. (1952). 16. FACCHIANOA. Roseto Valfortore. Tipografia Casa Sacro Cuore S. Agata di Puglia (Foggia), (1970). 17. GANSH. J. The Urban Villagers. Free Press, Glencoe, Ill. (1962).