Strong sodai support networks are of specific value in times of crises when people need information to provide them with a sense of identity, worthiness, and security.
It has been well documented that a crisis threatens a person's health status by lowering resistance to disease. The assault of crisis upon the mind and body is particularly devastating when inadequate and malfunctioning coping systems exist. Strong social support networks are of specific value in times of crises when people need information to provide them with a sense of identity, worthiness, and security. The nomenclature "social support networks" refers to the series of relationships with significant others that people develop in their lives by sharing common experiences. These networks act as coping mechanisms or support systems, which create a milieu in which persons care for one another. The elderly are particularly in need of strong social networks . '
An important issue for nurses is the identification of different social support patterns in selected elderly populations. Two primary limitations have been evident in past research:
1. Studies have been homogeneous and have failed to consider individual differences, and
2. The conceptualization and operationalization of social support measures have been inadequate.
The purpose of this study was to examine patterns of social support relative to gender and marital status in the aged and to use a more comprehensive measure of social support for elderly populations.
The elderly are at increased risk to the threat of illness. The elderly's way of life consists of such maturationai crises as the loss of a spouse, friends, or relatives through death or the highly mobile nature of our present society. In addition, decreases in physiological efficiency, including that of the stress response and the immune system and the preponderance of chronic diseases, increase their vulnerability. Cobb2 has found that social support in times of illness can reduce the amount of medication required and accelerate recovery. Accordingly, he has stated that social support can protect people in crisis from such problems as arthritis, depression, and alcoholism. Social ties act as a buffer and provide resources for coping with life strains. These, in turn, may increase a person's resistance to disease.3
Social support is related to both a strong sense of coherence and feelings of mastery. Antonovsky4 maintained that a strong sense of coherence is sustained by social supports, which in turn enable persons to mobilize internal coping resources during times of stress. Berkman and Syme5 also identified the important role of intact social networks in maintaining a person's well-being and strengthening resistance to disease. Studies done on elderly populations have repeatedly shown that social support serves as a buffer against social and traumatic losses such as retirement and widowhood.6·7 Because social support plays a significant part in health and recovery from illness, understanding individual differences in the composition of the elderly person's social support network is crucial if nurses are to plan and implement effective health care.
SOURCES OF SOCIOEMOTIONAL SUPPORT AND INSTRUMENTAL AID
Although many studies have considered the importance of social support to the elderly, few have addressed the issue of heterogeneity. Current research has not reflected population diversity, but has been based on the notion that all older adults behave in similar ways and have similar needs for social support. Although studies done by Babchuk8 and Lowenthal and Haven6 have shown that women have more close relationships than men and that married people have more than unmarried people, none have looked at the interactive effects of gender and marital status on social support. That is, no research has been found to describe differences in the composition of the social support systems of elderly married and unmarried males and married and unmarried females.
A second important issue is one of conceptualization and operationalization. Few studies have viewed social support in a multidimensional sense. Investigations by Weeks and Cuellar,9 Litwak and Szelenyi,10 Unger and Powell,11 and Shanas12 have defined social support as social contacts or helping networks. Using this definition they have attempted to describe with whom people interact and to whom they turn in times of need. Other investigators have denned social support as intimacy or closeness with others. Dean and Lin,13 Lowenthal and Haven,6 and Snow and Crapo14 have all found that close relationships with others buffer the effects of stress and are important to health and well-being.
None have attempted to combine these two concepts into a more comprehensive measure as suggested by Thoits.15 She defined social support as the degree to which a person's basic social needs are met through interaction with others. Accordingly, she described two aspects of social support. The first is the provision of socioemotional aid such as affection, understanding, acceptance, and esteem from significant others; and the second is the provision of instrumental aid such as advice and help with responsibilities. These two concepts were used in this study.
The data were collected as part of the second stage of a project titled "Service Delivery Arrangements for Rural Elderly in the Northeast." Eighteen minor civil divisions (MCDs) were randomly selected from six northeastern states: Pennsylvania, New Jersey, Vermont, Maine, New Hampshire, and West Virginia. These were labeled "sites." A combination of stratification, quota, cluster, and probability sampling was used to select these sites.16
Subjects were randomly selected through telephone exchanges in each site. A telephone exchange is defined as the first three digits of the number after the area code. One method used was random digit dialing. To accomplish this, telephone exchanges were identified for the MCD of concern.
A computerized list of randomly selected 4-digit numbers was generated for each exchange. Interviewers called each of the resulting 7 -digit numbers, discarding those numbers that were not working or at which there were no elderly. In some instances, the telephone exchanges did not coincide with the MCD that had been selected for study. That is, the exchange overlapped into neighboring MCDs not identified for study. In these cases, a second method was used which involved the generation of a computer file of all telephone directory listings for each MCD. Commercial listings were then deleted and the listings were randomly ordered by a computer, which assigned random numbers to each listing. Interviewers then called the numbers sequentially until elderly willing to be interviewed were identified.
A total of 50 respondents were interviewed per MCD for a total of 900 noninstitutionalized persons aged 65 years and older. In all, 6,585 telephone numbers were called to complete the 900 interviews. A refusal rate of 24% represented a combination of the number of elderly who refused to be interviewed and the number of family members who refused on behalf of the elderly living with them.
Each respondent's social support was measured in terms of socioemotional aid (affection, sympathy, understanding) and instrumental aid (information, help with responsibilities) as outlined by Thoits.15 Pfearlin et al17 have suggested that socioemotional aid comes with the exchange of intimate communication and the presence of trust. Accordingly, respondents were asked if there was someone to whom they felt they could tell anything, someone they could count on for understanding and advice. If the response was positive, they were asked to identify their relationship to that person (spouse, family, or friend). These were labeled confidants. The instrumental aid aspect of social support was measured by asking the respondents about those persons (spouse, family, friends, agencies, and paid helpers) who helped them with indoor household chores, transportation, and personal health.
For both measures of social support, respondents were categorized as having no support (O) or support (1) in any of the relational categories (spouse, family, or friends). Subjects could give an affirmative answer to more than one category. It was therefore possible for them to identify up to three confidants and up to six helpers in each category. However, for the purposes of this article, respondents were categorized as having no support (O) or support (1) in any of the relational categories (spouse, family, or friend).
Cross-tabular analysis was conducted. Three confidant categories and five helping categories were analyzed to test the interactive effects of gender and marital status on each of the eight categories. Statistical significance was tested using 2 x 2 chi squares for contingency, with a Yates correction.
Ages of respondents varied from 65 to 94. The sample was 95% white. Thirty-five percent (N=311) were males and 65% (N=589) were females. Fortyfour percent were married and 64% were retired at the time of interview. The majority of married elderly (54%) were males; the majority of nonmarried elderly (91%) were females.
Sources of social support and instrumental aid for these elderly by marital status and gender are presented in the Table. POT married elderly and unmarried elderly, patterns of social support differed according to gender. Married males confided in their wives and relied on them significantly more for help than did married females on their husbands. The chief sources of socioemotional support for married females were family and friends rather than spouse. No gender differences were found for family and friends, agency and paid helpers. For unmarried elderly there were no gender differences in socioemotional support. However, with regard to instrumental social support, females used family helpers, agency, and paid helpers more than males.
The results of this study indicate that there are significant differences in patterns of social support for dependent elderly on both gender and marital status. It is also evident that these differences are enhanced when multidimensional aspects of social support are used as measures.
For married elderly, it would seem that gender differences in socioemotional support could be due to gender roles. In a marital situation, the female is socialized to assume a supportive role and to bear the burden of much of the family's problems. Married males are socialized as providers and problem solvers and are generally not encouraged to deal with the affective aspects of family life. For this reason, married males turn to their wives for socioemotional support, but married women must rely on family and friends to fulfill their needs. Although it was not the purpose of this study to determine the gender of these family members and friends, it is probable that those who support elderly females are also female.
These same reasons could explain why married males rely more on their wives for instrumental aid than do married females on their husbands and why no significant differences were found in seeking help from family and friends, agencies, and paid help. Again, the married women would seem to be providing most of the instrumental aid with little outreach to other resources.
Among the unmarried there were not significant gender differences found in socioemotional support. For both males and females , patterns of socioemotional support were the same, indicating that gender roles are possibly more similar for males and females who are not married. However, there were differences in the use of instrumental aid; unmarried females indicated that they used all of the instrumental aids more than did the unmarried males. The gender differences in helping networks for the unmarried may be age related. It might be that because females live longer than males, there are more frail elderly females in the sample than there are males, and these respondents account for the gender differences in patterns of helping in this group.
Of interest is the data presented on agency helpers. Of the 900 respondents in the sample, only 40 (4%) used agency help. This could be due to several reasons. First, the elderly may have considered agencies to be a form of welfare and be too proud to seek that kind of help. Second, for these elderly at least, support networks were working well and nothing else was needed. Third, because these elderly were generally in good health (more than 60% reported good to excellent health) needs for agency help were minimal.
Implications for Nursing
There are several implications for nursing practice that emerge from the findings cited in this study. The most important is that the social support patterns of the elderly are highly differentiated and need to be considered in a heterogeneous rather than a homogeneous sense. Nurses need to assess the social support systems of elderly clients individually rather than making stereotyped assumptions. For example, the loss of a spouse for an elderly male may completely destroy his social support system and thus make him more at risk for health problems. A similar loss for an elderly female, although traumatic, may not be as difficult because of the additional support of family and friends. Knowing this, the nurse can foster the use of confidants other than the spouse, preferably with the aid of the wife as a liaison between husband and family and friends. This would provide the husband with a broader social support system in the event of his wife's death.
A second implication is that when working with elderly clients the nurse needs to realize the importance of minimizing network change. For elderly who are newly institutionalized, for example, this may mean providing for contact with friends and community groups as well as family. However, losses within a social support system may need to be replaced, particularly if a significant weakness in the network results.
Networks are subject to change. In our mobile society it is not uncommon for friends and relatives to move frequently from community to community leaving the elderly behind. Furthermore, the elderly often choose to remain in their community. On the other hand, when families move and take the elderly with them, a large portion of the social support system may be left behind.
Finally, this study revealed that few of the elderly in the sample used agency help. Should the chief reason be due to a view of "being too proud to accept welfare," the nurse needs to use tact in helping clients see agencies as "friends." Helping professionals such as nurses, doctors, counselors, and pastors are more likely to be perceived as acceptable help. A similar attitude of acceptability toward agencies needs to be developed.
Of utmost importance is aiding the client to maintain dignity while coping with crisis. By developing understanding of the client's culture, attitudes, beliefs, and values, the nurse will have a more sound base to assist, if necessary, in expanding the client's network. New possibilities, if presented within the client's individual context, will be more acceptable to him or her. Interventions must be nonthreatening to the client's pride and independence. Alternatives to an agency should be explored.
Nurses can help elderly strengthen their existing support systems by involving family and friends in their care in whatever way possible. This involvement might entail revitalizing "old" relationships and appraising the needs of persons within the network and their importance to the client as well as identifying ways in which they can play a significant role. Many times relatives and old friends are busy with their personal responsibilities and cannot become involved. If they are made aware that involvement may mean no more than occasional, brief but regular visits, they may be more willing to play an active part.
It is not the number or length of visits but their regularity that is important. Regular visits by a relative or friend convey interest and concern. The regular visits emphasize, "I am still around and interested should you need me." They do not pose a threat to the client's independence. Rather, the show of interest generally sparks the client's motivation to work even more diligently toward maintaining independence. The development and maintenance of close social support networks are crucial if the elderly are to remain healthy and independent for as long as possible.
Both the nurse and the elderly client need to identify the client's social support system and how it operates. The process of mutual assessment may enlighten the client to system assets of which he or she may have been unaware. Knowledge of the unique nature of the client's social support system affords the nurse and client an opportunity to develop strategies to expand, strengthen, and support the system and facilitate smooth exchanges within it.
Data presented from this study can help nurses and clients understand that social support systems of the elderly differ for married and unmarried males and married and unmarried females. In addition, these data show that the use of a more comprehensive measure of social support, one that measures socioemotional support as well as instrumental support, further expands our knowledge of the patterns of these networks in elderly populations. The nurse's assessment of the social support system of each elderly client, as well as the use and maintenance of the system, is crucial to the health and well-being of the client.
- 1. Alcalay R: The Need of Social Support for Health. Proceedings of 1980 Annual Meeting of the Society of Preventive Medicine, Tucson, Ariz, November 1980.
- 2. Cobb S: Social support as a moderator of life stress. Psychosom M ed 1976; 38(5):300-313.
- 3. Cassel J: The contribution of social environment to host resistance. Am J Epidemial 1976; 104(2): 107-123.
- 4. Antonovsky A: Health, Stress and Coping. San Francisco, Jossey-Bass Ine Pubs, 1979.
- 5. Berkman LF, Syme SL: Social networks, host resistance and mortality: A nine year follow-up study of Alameda County residents. Am J Epidemial 1979; 109(2): 186-204.
- 6. Lowenthal M, Haven C: Interaction and adaptation: Intimacy as a critical variable. Am Social Rev 1968; 33(1):20-30.
- 7. Palmore E, Cleveland WP, Nowlin JB,etal: Stress and adaptation in later life. J Gerontol 1979; 34(6):841-851.
- 8. BabchukN: Aging and primary relations./«/ J Aging Hum Dev 1979; 9(2): 137-151.
- 9. Weeks J, Cuellar J: The role of family members in the helping networks of older people. The Gerontologist 1981; 21(4):388-394.
- 10. Litwak E, Szelenyi I: Primary group structures and their functions: Kin, neighbors, and friends. Am Social Rev 1969; 34(4):461-481.
- 11. Unger D, Powell R: Supporting families under stress: The role of social networks. Family Relations 1980; 29(4):566-574.
- 12. Shanas E: The family as a social support system in old age. The Gerontologist 1979; 19(2): 169- 174.
- 13. Dean A, LJn N: The stress-buffering role of social support: Problems and prospects for systematic investigation. J Nerv Ment Dis 1977; 165(6) :403-417.
- 14. Snow R, Crapo L: Emotional bondedness, subjective well-being and health in elderly medical patients. J Gerontol 1982; 37(5):609-615.
- 15. Thoits P: Conceptual, methodological and theoretical problems in studying social support as a buffer against life stress. J Health Soc Behav 1982; 23(2): 145-159.
- 16. Crawford CO: Final Project Report: NEI 3 J , Service Delivery Arrangements for Older People in the Rural Northeast. University Park, PA, The Pennsylvania State University. To be published.
- 17. ftarlin LI, Lieberman MA, Menaghan EG, et al: The stress process. J Health Soc Behav 1981; 19(1):2-21.
SOURCES OF SOCIOEMOTIONAL SUPPORT AND INSTRUMENTAL AID