Approximately one third of older Americans live in rural areas. These elderly rural adults report greater physical impairment and more chronic illnesses than the urban aged (Preston, 1984). Although stress is well recognized as a significant factor in the development of acute and chronic illnesses in adults, its relationship to the perceived health status of the rural aged is not well documented.
Selye (1956) established that the body responds to physical and emotional stress with certain physiologic changes; this is known as the stress alarm system. This system involves all the body's major organs. When the stress alarm system is activated by a noxious stimulus known as a stressor, bodily changes occur that may have adverse effects on the individual's health status. For example, stress may result in increased gastric acid secretions that, in turn, increases the risk of gastric ulcer disease. The risk of heart disease also is greater as more free fatty acids are released and blood vessels constrict.
Krause (1987) pointed out that there are two major sources of stress in an individual's life: life events and chronic strain. Stressful life events are ". . . discrete occurrences, limited by time, that happen (either predictably or unpredictably) at various points in life." Chronic life strains are problems that continue for an undetermined length of time.
Pearlin (1989) suggested that life events do not exert as great an impact on an individual's well-being as chronic strain. It is the quality and meaning of the change brought about by the event that results in stress rather than the event itself. Therefore, stressful events and chronic strains are often related to one another. One may lead to other. For example, retirement may not be perceived as a stressful event by the person who has plans to travel with his or her spouse. Consequently, chronic strain never occurs. In contrast, the individual who dreads the retirement event due to the loss of companionship is likely to experience chronic strain. This strain may later lead to the stressful event of an acute illness.
According to Pearlin (1989), the individual's sensitivity to an event may be influenced by age, gender, marital status, race, economic status, and place of residence. Although some previous research has been conducted on stress and health status of the aged, it has focused on racial differences, marital status, and gender differences in urban populations (Krause, 1987; Preston, 1990; West, 1983). Furthermore, studies that have considered stress and health in older populations have used instruments designed for use with middle-aged adults (Stokes, 1988).
Stressful events and chronic strains may differ in the elderly. There is a significant lack of research using appropriate data collection tools to measure stress and perceived health status in the rural aged. Without adequate information regarding this group of elderly, it is difficult to develop appropriate nursing interventions to mediate the effects of stress on health status.
The purposes of this study, therefore, were the following: to identify the stressful life events and chronic strains of the rural elderly; and to describe the relationship between stress and perceived health status in this group of older adults according to age, gender, and marital status.
This study sought answers to the following questions:
* What is the average stress level of the rural elderly?
* What are the most frequently reported stressful life events and chronic strains of the rural elderly?
* What is the perceived health status of the rural elderly?
* What is the relationship between stress levels and perceived health status in the rural elderly according to age, gender, and marital status?
Data for this study were collected using the Stokes-Gordon Stress Scale (SGSS) and the Perceived Health Status Questionnaire (Stokes, 1988).
The SGSS was specifically designed to measure stress in adults 65 years of age and over. It lists 104 age-specific events and situations that may lead to stress or chronic strain in the aged. These items were elicited by reviewing the literature, interviewing adults over 65 years of age, and consulting with gerontological nurse experts (Stokes, 1988). Examples of stressful events include "giving up or losing a driver's license," "being judged legally incompetent," "retirement," and "death of a grandchild." Items addressing chronic strain include "change in ability to do own selfcare," "constant or recurring pain or discomfort," "loneliness or aloneness," "decreasing eyesight," and "not having enough money for food or medicine."
Based on data from 43 individuals over the age of 65, the authors of the SGSS used a q-sort to determine the ranking and weight of the 104 stressors. Scores range from 100 (most stressful) to 0 (least stressful). Items on the SGSS are presented out of rank order and participants are requested to indicate stressors they are currently experiencing (Stokes, 1988). The scale can be completed in approximately 15 minutes.
Reliability and validity of the SGSS were established by its authors (Stokes, 1988). Test-retest reliabilities were conducted on three separate samples. The interval between tests was 2 weeks, with resulting Pearson sample correlation coefficients of .98, .91, and .90 respectively (p<.00l). Cronbach's alpha (for internal consistency) was .86.
Frequency of Most-Reported Stressors in Rural Elderly (N =82)
Content validity of the SGSS was established by the methods used to determine the list of 104 items included on the instrument. Concurrent validity with the Holmes and Rahe Social Readjustment Rating Scale was determined to be r=.81 (p = . 001) (Stokes, 1988).
The Perceived Health Status Questionnaire asked subjects to choose one statement indicating their current health status. Choices ranged from 1 ("I think my present health status is very good") to 5 ("I think my present health status is very poor"). The practice of asking subjects a single question to rate their own health is the most frequently used method to determine the assessment of one's health. Subjectively rated health status correlates strongly with physicians' assessments of health (Linn, 1980; Weinberger, 1987). Data were analyzed using descriptive statistics and Pearson's Product-Moment Correlation procedure.
A convenience sample of 50 women and 32 men participated in this study. Subjects were noninstitutionalized and lived in rural areas of the western United States. Many of the communities were separated from one another by mountain ranges. Impassable roads, a common occurence in winter, resulted in periods of isolation.
Subjects ranged in age from 64 to 98 years old, with a mean of 75.12 years. Forty-nine participants were widowed and 33 were married. The number of years of education ranged from 8 to 22, with a mean of 13.94.
Although the results of this study must be interpreted with caution due to the nature of the sample, the findings suggest that the rural elderly experience a high level of stress and a "fair" to "poor" level of health. Stress scores on the SGSS for these subjects ranged from 75 to 2330, with a mean of 1589.59 and a standard deviation of 465.71. The average perceived health status of the sample was 3.69, with a range of 1 to 5 and a standard deviation of .43. Of the 82 study participants, only 13 reported that their current health was "very good," while 37 indicated that it was "very poor."
The most frequently occurring stressful life events and chronic strains reported by subjects in this study are shown in the Table. As can be seen, loneliness was indicated as a chronic problem by 61.6% of the subjects. Sixty-three percent reported that having a decreasing number of friends was a chronic stressor. Not having enough time with children or grandchildren was reported by 45.2%; missing children and grandchildren was reported by 47.9%.
Events involving losses were frequently indicated as stressful: 49.3% had lost a family member or friend to death within the previous year, while 47.9% had experienced the death of a loved pet. The loss of a driver's license was selected by 50.6% of the subjects as a stressful event.
Chronic strains and stressful events involving changes in health status and self-care abilities were reported by a significant number of subjects. More than 64% reported sleep changes, 45.2% indicated decreases in eyesight and hearing, and 39.7% selected decreases in mental abilities as stressors. The need to rely on a cane, wheelchair, or hearing aid was reported by 46.5% of the sample as stressful. Slightly more than 50% of the subjects experienced a change in self-care ability and the need to depend on others for assistance with activities of daily living as chronic strains.
When the relationship between stress levels and perceived health status in the rural aged was considered, it was found that the higher the reported stress, the poorer the perceived health status (r = -.91, p<.001). Older individuals experienced greater stress (r = .77, p<.00l) and poorer health (r = -.84, p<.001) than younger ones. Married subjects reported better health and less stress than single ones (r=.67, p<.05 and r = .71, p<.01 respectively). There were no significant relationships between gender and stress levels or gender and perceived health status for subjects in this study.
As indicated by the results of this study, the rural elderly experience high levels of stress, due to life events and chronic strains, and poor-to-fair health. The most frequently reported stressful events and chronic strains included those involving the loss of family, friends, and pets; loneliness; sleep pattern changes; sensory and cognitive changes; and decreased abilities to manage self-care activities. Other commonly reported stressors included financial concerns, illness or hospitalization of a family member or self, loss of a driver's license, changes in social activities, dependence on others, and wishing that parts of their lives had been different. It is possible that the relative isolation of living in a rural environment intensifies the stress of these events and the strains of life in the aged.
The deaths of those who are close to the rural elderly may be felt more acutely due to the many miles and vast terrain that separate them from remaining family and friends. Subjects in this study identified few visits from children and grandchildren and missing children and grandchildren as stressful. They also indicated that a decreasing number of friends was a strain. The lack of family visits and the stress caused by fewer friends may be due to the fact that travel is complicated by environmental and climactic factors that are inherent to rural areas.
Consequently, the support that would be provided by close family and friends is not available to this group of elderly. The loss of a pet who has provided love, companionship, and the need-to-be-needed may compound the sense of isolation experienced by the rural aged. Older individuals who have lost a driver's license are at particular risk for increased isolation and loneliness because their social and recreational activities depend on others to visit and provide transportation to events. Public transporatation is usually not available in rural areas, making it almost impossible for the elderly to maintain any independence once they are unable to drive.
Similarly, decreases in vision, hearing, and mental abilities that are experienced by the aged may be particularly stressful for those in rural areas because they compound the sense of isolation, need for assistance, and loneliness. With sensory losses, the aged may have difficulty completing daily activities and meeting self-care needs successfully. There may be no one who is readily available to assist them in meeting these needs. Family and friends may be too far away and appropriate health care providers may not be available. However, these elderly subjects report an increased dependence on others to be a stressor. The strain of dealing with changes in physical and mental health and the consequent difficulty in caring for themselves in an independent manner become stressors that create concern for them.
Illness and /or hospitalization of self or family members also were rated as stressful by subjects in this study. Although these findings were expected, the lack of and/or difficult access to adequate and appropriate health care in rural areas may result in additional stress for the rural elderly. These individuals must frequently travel to large urban centers, located at great distances from their homes, for needed health care.
The rural aged also may find that they are the sole caregiver for an ill family member. Few, if any, community resources are available for support in many rural areas. Such resposibility increases the level of stress. Financial constraints and difficult travel may confound these findings. It is not particularly unexpected that subjects with a lower stress level reported a higher perceived health status. These findings support Selye's (1956) theory of stress. They also support the relationship between stressful life events, chronic strain and health as proposed by other researchers (Krause, 1987; Pearlin, 1989).
It also is not surprising that older and single subjects reported that they had experienced more stressful life events, chronic strains, and poorer health in the past year than those who were younger and married. Oldold individuals (those over 85) typically have more health problems and experience more losses in their social networks than those between 65 and 84 years old. They also are more likely to be widowed, thus, having lost a significant source of companionship and support.
IMPLICATIONS FOR NURSING
There are several implications of these findings for nurses who practice in rural areas. First, they must be aware that there is a direct relationship between stress levels and perceived health status in this group of older adults. Those who experience the most stress are likely to have the poorest health. Therefore, it is important for nurses to assess the amount of stress that their clients are experiencing and to be alert to its impact on their health. The SGSS7 may be a useful assessment tool for use in detennining the total stress level of these individuals.
Secondly, nurses should be cognizant that certain events and strains are more stressful than others for the rural aged. Those stressors involving loss and changes in financial status and self-care abilities deserve special attention in the assessment of stress in these clients. These sources of stress may be of greater concern for them due to the isolation often inherent in living in a rural area.
Finally, it is important for nurses to develop strategies specifically designed to mediate the stress experienced by the rural elderly. While some current techniques may be useful in reducing stress levels, such as progressive relaxation and exercise, others may be more appropriate for the urban aged. For example, reliance on a variety of readily available community resources to assist with activities of daily living may be a feasible alternative for someone residing in a large city. It is not usually an option for those living in a community of 3,000 that is located 125 miles from the closest urban area. Research is necessary to determine how to best meet the stress-reducing needs of these rural elderly individuals. Reducing their stress could result in improved health and a better quality of life for them.
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Frequency of Most-Reported Stressors in Rural Elderly (N =82)