Beruflich Dokumente
Kultur Dokumente
1177/0898264304265778
JOURNAL OF AGING AND HEALTH / August 2004
Giles et al. / SOCIAL NETWORKS AND DISABILITY
PATRICIA A. METCALF
GARY F. V. GLONEK
MARY A. LUSZCZ
GARY R. ANDREWS
Objective: To investigate the effects of total social networks and specific social networks with children, relatives, friends, and confidants on disability in mobility and
Nagi functional tasks. Methods: Six waves of data from the Australian Longitudinal
Study of Ageing were used. Data came from 1,477 participants aged 70 years or older.
The effects of total social networks and those with children, relatives, friends, and
confidants on transitions in disability status were analyzed using binary and multinomial logistic regression. Results: After controlling for a range of health, environmental, and personal factors, social networks with relatives were protective against
developing mobility disability (OR = 0.89; 95% CI = 0.79 to 1.00) and Nagi disability
(OR = 0.85; 95% CI = 0.74 to 0.96). Other social subnetworks did not have a consistent effect on the development of disability. Discussion: The effects of social relationships extend beyond disability in activities of daily living. Networks with relatives
protect against disability in mobility and Nagi tasks.
Keywords:
transitions; Australian Longitudinal Study of Ageing; activity limitations; disability; social networks
517
518
519
Data for this research came from the Australian Longitudinal Study
of Ageing (ALSA), a large epidemiological study of aging carried out
520
To date, six waves of data have been collected from these participants. Waves 1 to 4 were annual interviews beginning in 1992, Wave 5
occurred in 1998, and Wave 6 was conducted in 2000 to 2001. Waves
1, 3, and 6 involved both clinical assessments and detailed personal
interviews that captured biomedical, behavioral, economic, social,
and environmental aspects of participants lives. Waves 2, 4, and 5
consisted of a short telephone interview that captured information on
major domains of health and lifestyle, including physical function.
DISABILITY
Two complementary measures of self-reported disability were considered in the present study. The first of these, mobility, is derived
from Rosow & Breslau (1966). Participants were defined as having no
mobility disability if they reported they were able to walk up and
down a flight of stairs and walk half a mile without help. If either or
both of these activities could not be completed, they were classified as
521
having a mobility disability. Other studies have used a similar dichotomous measure of mobility (Beckett et al., 1996; Guralnik et al.,
1993; Mendes de Leon et al., 1999).
The second disability measure was derived from questions developed by Nagi (1976). Participants reported their level of difficulty in
performing five tasks (pushing or pulling large objects, stooping or
crouching or kneeling, lifting or carrying 10 pounds, reaching or
extending arms, and writing or handling small objects). There were
five response categories for each task, namely, no difficulty, a little
difficulty, some difficulty, a lot of difficulty, or just unable to do
it. Participants were defined as having no Nagi disability if they
reported no more than a little difficulty for all five Nagi questions. Participants who reported at least some difficulty for at least one of the
five questions were classified as having a Nagi disability (Beckett
et al., 1996).
For Waves 1 through 6, participants could have missing values on
one or more of the component disability questions. Participants with
missing values for one or both of the mobility questions at any wave
were coded as missing for that wave, unless one of the nonmissing
items indicated mobility disability. In this case, participants were
coded as having a mobility disability (Mendes de Leon et al., 1999).
Similarly, the response for participants with missing values for at least
one of the five Nagi tasks within a wave was coded as missing for that
wave, unless a nonmissing response to one of the tasks indicated disability. In this case, participants were classified as having a Nagi disability. Participantsmortality status was tracked throughout the study
via searches of official death certificates conducted by the Epidemiology Branch of the Department of Human Services in South Australia.
SOCIAL NETWORKS
Structural measures of social networks were hypothesized as predictors of transitions to and from disability. Following Glass et al.
(1997), confirmatory factor analyses of the Wave 1 data were used
to develop measures of social networks, and the analyses showed that
children, relatives, friends, and confidants were important social subnetworks for the ALSA participants (Giles, Metcalf, Anderson, &
Andrews, 2002). The children subnetwork combined information on
522
the number of children, proximity of children, and frequency of personal and phone contact with children. The relatives subnetwork was
composed of the number of relatives, apart from spouse and children,
to whom the participant felt close, and the frequency of personal and
phone contact with such relatives. Similarly, the friends subnetwork
captured the number of close friends, personal contact and phone contact. The confidant subnetwork reflected the existence of confidants
and whether the confidant was a spouse. A total social network score
was calculated as the sum of the children, relatives, friends, and confidant subnetwork scores. All of the component variables, such as number of children and frequency of contact with children, were selfreported and standardized prior to the derivation of the social network
variables.
COVARIATES
The effects of a number of personal, environmental, and healthrelated factors on transitions to and from disability were considered in
the analyses to control for confounding. These covariates were derived from self-reported data from the Wave 1 interview and were
operationalized as follows.
Age group was classified as 70 to 74 years, 75 to 79 years, 80 to 84
years, and 85 years or older on December 31, 1992. Gender was also
included as a covariate, as was geographic area of residence. Place of
residence was classified as community or residential care. Current
marital status was classified as married/partnered or not married.
Household income was coded as less than or equal to $AUD12,000
per annum, more than $AUD12,000 per annum, or missing. This cutoff point for income was chosen because it was similar to the single
persons aged pension rate in 1992. The age at which the participant
left full-time education was categorized as less than or equal to 14
years of age or more than 14 years of age.
Self-rated health was classified as excellent/very good, good,
and fair/poor. The number of chronic conditions was derived from
self-reported information on whether each participant had ever suffered from arthritis, cancer (excluding non-melanocytic skin cancer),
chronic bronchitis or emphysema, diabetes, fractured hip, heart
attack, heart condition, hypertension, myocardial infarction, or
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524
Two approaches were used to ascertain the effects of social relationships on mobility and Nagi disability. First, the participants who
were not disabled at the previous wave were selected. The effects of
social relationships on the transition to disability (binary logistic regression) or disability/missing/deceased (multinomial logistic regression) at the subsequent wave were estimated. These models were of
the form logit Pr(Yij = 1|Yij1 = 0) = xij0. Similarly, participants who
were disabled at the beginning of each wave were selected, and the
effects of social relationships on remaining disabled (binary logistic
regression) or disabled/missing/deceased (multinomial logistic
regression) were estimated. These models were of the form logit
Pr(Yij = 1|Yij 1 = 1) = xij1. Second, models that used all data were fitted
to estimate the effects of social networks on disability (Diggle,
Heagerty, Liang, & Zeger, 2002). Disability status in the previous
wave was used as a covariate in this second set of models. These models are written as logit Pr(Yij = 1|Yij1 = yij1) = xij + yij1xij. Simpler
nested models that excluded the interaction between disability in the
previous wave and covariate terms were also assessed and fitted where
appropriate. We assumed that the missing data mechanisms were
ignorable and missing at random (Beckett et al., 1996; Diggle et al.,
2002). Stata was used in all analyses (StataCorp, 2001).
Results
The responses to the covariates for the 1,477 participants are summarized in Table 1. The average age at selection was 77.2 5.9 years,
and females represented 61% of the weighted sample. More than half
of the participants had left school before the age of 15 years, and half
of the sample was married/partnered. Although the majority of participants lived in the community, 137 of the participants were in residential care. Participants most commonly had one morbid condition,
and 14% of the participants showed signs of cognitive impairment.
Almost half of the participants did not exercise. The social network
scores had ranges of 1.67 to 1.17 (children), 1.05 to 2.02 (other relatives), 1.54 to 1.19 (close friends), 1.68 to 0.77 (confidants), and
5.69 to 4.97 (total).
Tables 2 and 3 present the wave-to-wave transitions in mobility and
Nagi disability during the course of the study. Table 2 shows that for
525
Table 1
Frequencies (%) for Covariates Used in Modeling Disability Measures
Covariate
Age at selection
70 to 74
75 to 79
80 to 84
85+
Gender
Male
Female
Place of residence
Community
Institution
Marital status
Married
Not married
Missing
Age left school
15 years
14 years
Missing
Household income
> $12,000
< $12,000
Missing
Number of morbid conditions
0
1
2
3
4
Cognitive impairment
No impairment
Impairment
Missing
Self-rated health
Excellent/very good
Good
Fair/poor
Missing
Depressive symptomatology
No depressive symptoms
Depressive symptoms
Missing
Unweighted %
Weighted %
379
352
341
405
25.7
23.8
23.1
27.4
39.4
29.1
18.5
13.0
928
549
62.8
37.2
39.4
60.6
1,340
137
90.7
9.3
93.5
6.5
771
705
1
52.2
47.8
51.5
48.5
633
830
14
43.3
56.7
44.4
55.6
779
590
108
52.7
39.9
7.3
51.9
41.2
6.8
264
494
421
190
108
17.9
33.4
28.5
12.9
7.2
16.4
31.5
30.0
14.4
7.7
1,246
199
32
84.8
15.2
86.2
13.8
563
440
469
5
38.2
29.9
31.9
39.2
31.3
29.5
1,205
195
77
81.6
13.2
5.2
83.9
12.0
4.1
(continued)
526
Table 1 (continued)
Covariate
Hearing difficulty
No
Yes
Missing
Vision difficulty
No
Yes
Missing
Alcohol problem
No
Yes
Missing
Smoking status
Never smoker
Ex-smoker
Current smoker
Missing
Sedentary
No
Yes
Missing
Unweighted %
Weighted %
726
746
5
49.3
50.7
56.2
43.8
1,035
375
67
73.4
26.6
77.4
22.6
1,401
65
11
95.6
4.4
96.0
4.0
661
677
123
16
45.2
46.3
8.4
52.8
38.3
8.8
794
663
20
54.5
45.5
55.2
44.8
527
Table 2
Transitions From Each Mobility State During Six Waves of ALSA
Disability Status
Disability Status
at Previous Wave
No disability
1-2
2-3
3-4
4-5
5-6
Disability
1-2
2-3
3-4
4-5
5-6
Missing
1-2
2-3
3-4
4-5
5-6
Deceased
2-3
3-4
4-5
5-6
No
Disability
(%)
Disability
(%)
Missing
(%)
73.2
77.0
75.0
65.9
54.0
15.6
15.0
14.6
17.5
19.4
24.3
18.3
15.1
13.4
7.0
23.1
24.4
19.8
9.5
8.6
Deceased
(%)
Total n
8.8
5.5
7.4
8.6
19.3
2.4
2.5
3.0
8.0
7.3
987
841
761
663
510
57.7
65.7
66.7
54.1
44.0
10.4
5.2
7.2
11.5
17.6
7.6
10.8
11.0
21.0
31.4
473
429
441
418
357
52.9
23.3
11.4
10.6
10.1
8.8
44.3
65.7
67.8
49.4
5.2
8.0
3.1
12.1
31.9
17
145
134
179
230
62
141
217
380
Note. Results were weighted according to the sampling scheme. ALSA = Australian Longitudinal Study of Ageing.
Results are presented for participants (a) who were not disabled at
the previous wave, (b) who were disabled at the previous wave, and (c)
using all available data.
The binary logistic regression analyses, summarized in Table 4,
showed there was a protective effect of relatives network on developing mobility disability in the overall analysis and a marginal effect of
528
Table 3
Transitions From Each Nagi State During Six Waves of ALSA
Disability Status
Disability Status
at Previous Wave
No disability
1-2
2-3
3-4
4-5
5-6
Disability
1-2
2-3
3-4
4-5
5-6
Missing
1-2
2-3
3-4
4-5
5-6
Deceased
2-3
3-4
4-5
5-6
No
Disability
(%)
Disability
(%)
66.2
61.2
69.9
64.8
35.9
Missing
(%)
Deceased
(%)
Total n
22.2
31.9
22.0
20.7
37.6
8.2
4.9
5.0
6.8
19.4
3.4
2.0
3.1
7.7
7.1
577
569
444
442
376
20.9
11.8
15.4
12.5
5.7
65.1
74.5
70.8
60.6
51.8
9.4
5.7
6.4
10.4
18.3
4.6
8.0
7.4
16.5
24.2
879
714
758
655
495
23.1
24.4
19.8
9.5
8.6
52.9
23.3
11.4
10.6
10.1
8.8
44.3
65.7
67.8
49.4
15.2
8.0
3.1
12.1
31.9
21
132
134
163
226
62
141
217
380
529
Table 4
Dichotomous Disability Analyses: Effects of Social Network Variables for Transitions to Mobility and Nagi Disability for Participants Initially Not Disabled, Initially Disabled, and Overall
Mobility
Nagi
OR
95% CI
OR
95% CI
0.97
0.91
1.01
1.13
0.99
0.83-1.14
0.77-1.07
0.86-1.20
0.94-1.35
0.92-1.07
.720
.236
.862
.190
.811
0.93
0.84
0.97
0.90
0.91
0.79-1.10
0.73-0.98
0.82-1.16
0.75-1.08
0.84-0.99
.380
.026*
.766
.258
.022*
1.14
0.81
0.91
0.97
0.97
0.92-1.41
0.66-1.01
0.72-1.16
0.75-1.27
0.87-1.08
.229
.063
.450
.847
.579
0.94
0.91
0.91
1.03
0.94
0.79-1.11
0.76-1.09
0.76-1.09
0.85-1.24
0.87-1.02
.472
.313
.297
.793
.140
1.05
0.87
1.02
1.09
1.00
0.93-1.19
0.76-0.98
0.90-1.16
0.95-1.25
0.94-1.06
.394
.027*
.756
.223
.880
0.98
0.84
0.91
0.96
0.92
0.85-1.12
0.74-0.96
0.79-1.05
0.82-1.12
0.86-0.98
.761
.012*
.210
.625
.014*
Table 5 shows the effects of social networks on transitions to disability using all data in multinomial logistic regressions.
For those participants who were not initially disabled in mobility,
networks with children had a significant protective effect against
being missing (Table 5). The effect of networks with relatives was a
significant predictor of death. Total social networks were protective
against having a missing response.
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Table 5
Polytomous Disability Analyses: Effects of Social Network Variables for Transitions to Mobility
Disability and Nagi Disability for Participants Initially Not Disabled, Initially Disabled, and
Overall
Mobility
Nagi
OR
95% CI
OR
95% CI
0.98
0.78
0.97
0.84-1.15
0.66-0.93
0.78-1.20
.823
.005*
.750
0.95
0.81
0.94
0.80-1.12
0.64-1.02
0.71-1.25
.522
.074
.692
0.89
0.92
1.36
0.76-1.04
0.77-1.10
1.10-1.68
.149
.337
.005*
0.85
0.94
1.13
0.73-0.98
0.75-1.18
0.87-1.46
.027*
.592
.364
1.03
0.89
0.93
0.88-1.21
0.74-1.08
0.73-1.17
.735
.231
.511
0.97
1.17
0.93
0.82-1.15
0.91-1.52
0.71-1.21
.755
.225
.565
1.12
0.99
1.00
0.94-1.34
0.82-1.20
0.77-1.29
.195
.950
.978
0.90
0.90
1.00
0.75-1.07
0.68-1.19
0.71-1.41
.220
.442
.984
0.99
0.90
1.04
0.92-1.07
0.83-0.98
0.92-1.17
.842
.014*
.552
0.92
0.95
1.01
0.85-0.99
0.84-1.07
0.87-1.16
.027*
.361
.905
1.13
0.92
1.10
0.92-1.39
0.70-1.21
0.86-1.39
.244
.532
.446
0.97
0.74
0.96
0.82-1.15
0.60-0.92
0.79-1.18
.742
.007*
.713
0.82
0.90
0.88
0.67-1.00
0.68-1.20
0.69-1.12
.054
.481
.283
0.91
0.94
1.05
0.76-1.08
0.74-1.20
0.84-1.32
.288
.638
.645
0.92
0.82
0.74
0.73-1.16
0.61-1.11
0.56-0.97
.470
.205
.032*
0.93
0.75
0.78
0.78-1.11
0.60-0.95
0.62-0.98
.430
.017*
.035*
0.96
0.89
0.83
0.74-1.26
0.63-1.24
0.60-1.13
.784
.482
.233
1.02
1.05
0.93
0.84-1.23
0.82-1.34
0.73-1.18
.842
.724
.560
531
Table 5 (continued)
Mobility
Total Network
Disabled
Missing
Deceased
All data
Children
Disabled
Missing
Deceased
Relatives
Disabled
Missing
Deceased
Friends
Disabled
Missing
Deceased
Confidants
Disabled
Missing
Deceased
Total network
Disabled
Missing
Deceased
Nagi
OR
95% CI
OR
95% CI
0.96
0.92
0.92
0.87-1.07
0.80-1.06
0.81-1.04
.491
.240
.162
0.95
0.88
0.93
0.88-1.03
0.79-0.97
0.84-1.04
.239
.012*
.201
1.04
0.82
1.00
0.93-1.16
0.71-0.94
0.86-1.15
.530
.005*
.967
0.99
0.79
0.97
0.86-1.14
0.67-0.93
0.82-1.15
.895
.005*
.758
0.89
0.94
1.07
0.79-1.00
0.81-1.08
0.93-1.24
.042*
.379
.354
0.85
0.88
1.00
0.74-0.96
0.75-1.04
0.84-1.18
.011*
.137
.959
1.03
0.91
0.86
0.92-1.15
0.78-1.06
0.73-1.00
.646
.231
.051
0.96
0.91
0.83
0.84-1.10
0.77-1.08
0.70-0.99
.579
.301
.034*
1.08
1.00
0.93
0.95-1.23
0.85-1.17
0.79-1.10
.225
.964
.414
0.96
0.94
0.90
0.83-1.11
0.78-1.13
0.74-1.10
.589
.529
.298
1.00
0.92
0.97
0.94-1.05
0.86-0.99
0.90-1.05
.900
.022*
.440
0.94
0.89
0.93
0.88-1.00
0.82-0.96
0.85-1.01
.036*
.003*
.085
532
friends had a marginally significant protective effect against being deceased by the subsequent wave.
Networks with confidants had no effects on mobility disability in
the multinomial logistic regression analyses.
Similar analyses were undertaken for disability in Nagi tasks
(Table 5). For the participants who were not initially disabled, there
was a protective effect of relatives and total social networks against
becoming disabled.
Restricting the analyses to those participants who were initially disabled in Nagi tasks showed a significant protective effect of the children, friends, and total social networks against a missing response.
The friends network was also a significant protective factor against
death. Neither relatives nor confidant networks had an effect on any of
the outcomes among the initially Nagi-disabled participants.
When all available data were analyzed, a significant protective
effect of larger children network on missing status was observed. Networks with relatives had a significant protective effect against Nagi
disability. Networks with friends protected against death by the subsequent wave. Total social networks had a significant protective effect
against being disabled or missing. The effect of networks with confidants was not significant for any of the three outcome states of Nagi
disability.
Discussion
The effects of structural components of social relationships on disability in mobility and Nagi tasks were analyzed in this study. After
controlling for a wide range of personal, environmental, and healthrelated factors, there were persistent protective effects of social networks on disability. However, the protective effects varied according
to the type of social network and were strongest for relatives.
For mobility disability, the results differed depending on whether
the analyses were based on the two-category (binary logistic regression) or the four-category (multinomial logistic regression) definition
of disability. The strongest effect of social subnetworks was that for
relatives in the binary logistic regression. However, the multinomial
logistic regression suggested an effect of relatives in preventing
533
mobility disability among those not already disabled as well as overall. No other subnetworks had a significant effect on the development
of or recovery from mobility disability. In contrast, Mendes de Leon
et al. (2001) found that more frequent contact with friends decreased
the risk of developing mobility disability, and contact with relatives
had no effect on the development of mobility disability. Earlier work
by these authors suggested the effects of social subnetworks, and total
social networks on mobility were not statistically significant (Mendes
de Leon et al., 1999). Our analysis shows that specific social networks
are of moderate importance in preventing mobility disability and suggest that networks with relatives may have particular effects on the
development of mobility disability.
Both the binary and multinomial analyses showed that relatives
networks were important in protecting against Nagi disability. Unger
et al. (1999) reported that more social ties was associated with less
Nagi disability 7 years later but did not present a breakdown of the
effects of specific types of social networks on Nagi disability. Given
the paucity of literature concerning the effects of social networks on
Nagi disability, we believe our results represent an important first step
in the consideration of specific types of social networks on Nagi disability, and that additional research in this area is necessary.
Taken together, our findings show that social networks with relatives may be particularly important in preventing the development of
disability or promoting recovery from mobility and Nagi disability.
This adds to the work of Seeman, Bruce, and McAvay (1996), who
showed that women with more close ties with relatives were less likely
to experience the onset of new or recurrent ADL disability. Our findings suggest that social networks with relatives have effects in the disablement process that precede the onset of ADL disability and that
disability in mobility and Nagi tasks are affected by social networks
with relatives.
The analyses showed that networks with children and total networks were protective against having a missing response for both outcomes at subsequent waves. Children were important contacts in the
ALSA study when tracing participants at Waves 2 through 6, and this
may explain the protective effect of children network against missing
status. It is also possible that networks with children provide more
534
535
needs could negate any benefits that might come from networks with
confidants.
Our statistical approach has extended previous work concerning
disability transitions (Anderson et al., 1998; Beckett et al., 1996;
Mendes de Leon et al., 1997; Mendes de Leon et al., 1999; Mendes de
Leon et al., 2001; Rudberg, Parzen, Lamond, & Cassel, 1996). The
findings from both sets of analyses presented here suggest consistent
effects of networks with relatives on preventing Nagi disability and
slight evidence of an effect of relatives networks on preventing mobility disability. To our knowledge, this is the first report to systematically compare these analytic approaches in examining the effect of
social networks on transitions in disability.
The results from the present study raise important questions about
how social networks with relatives affect disability in later life. Several pathways have been suggested to explain the effects that social
relationships have on health (Berkman, 1985). Under one hypothesized pathway, social ties influence the adoption of health behaviors,
both positive and detrimental, and also influence the success of behavior change. One interpretation of our findings is that relatives, in
particular, offer advice about better health habits and access to health
services, and act as role models. As well, participants may be more
receptive to advice offered by relatives than to advice offered by a
child, spouse, or friend. Burg and Seeman (1994) reviewed some of
the negative effects of family members on health and showed that
spouses in particular may promote poor health habits. It is possible
that relatives, in contrast to children and spouses, offer health advice
less frequently, which makes its reception more welcome. In this way,
it is possible that participants with larger relatives networks have a
lower risk of developing disability because of the preventive health
behaviors that the networks with relatives foster. Relatives also possibly share early-life environments and health behaviors, so that relatives networks may be a proxy measure of genetic factors, including
survivorship and health.
Another possible pathway is a direct link between physiological
mechanisms and social relationships, with subsequent beneficial effects on disability. More positive, supportive relationships with relatives may be associated with beneficial physiological effects, which in
turn could promote recovery from disability and prevent transitions to
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