About one third of American adults 65 years and older live in a rural area. This group of elders experiences greater physical impairment and more chronic illnesses than older adults who live in urban settings. Stress is well recognized as a significant factor in the development of physical illness in adults. It is also well established that the stress that leads to crises and illness may be buffered by social support. The purpose of this study was to examine the stressful life events, social support, and perceived physical health status of older adults living in isolated frontier areas of the western United States. The influence of age, gender, and marital status on these variables was also investigated.
Krause (1987) suggests that life events and chronic strains are the primary sources of stress in one's life. He defines stressful life events as discrete and time-limited occurrences that are predictable or unpredictable and that happen at various times in one's life. In contrast, chronic strains are characterized as problems in one's daily life that continue for an unpredictable, yet typically prolonged period of time (Krause, 1987).
Stressful life events may have less of a negative impact on wellbeing than chronic strain (Pearlin, 1989). It is the meaning and quality of the change precipitated by the event that results in stress, rather than the event itself. Chronic strains and stressful events are commonly related to one another, and one may lead to the other. For example, older adults who look forward to retiring so they can travel may not see the retirement event as a stress. Chronic strain does not occur. However, those who view retirement as a negative event because of the loss of companionship and usefulness may develop chronic strain. As time passes, this strain may precipitate the event of an acute illness.
Pearlin (1989) proposes that age, gender, marital status, and place of residence influence the individual's sensitivity to stressful events and chronic strains. Other researchers (Berkman & Syme, 1979; Bowling & Charlton, 1987; Cohen, Teresi, & Holmes, 1987; Hinkle, 1987; Lin, Simeone, Ensel, & Kuo, 1979) have found that social support plays an important role in one's vulnerability to the stress and strain of life. The stress-buffering model mandates an interaction between social support and stress because strong social support significantly decreases the negative effects of stress (Callaghan & Morrisey, 1993; Wheaton, 1985).
Social support networks provide individuals with security, worthiness, and a sense of identity during times of crisis (Preston & Mansfield, 1984; Reinhardt, 1996). These networks range from an elaborate array of people to a supportive encounter between two individuals. The social support provided by the network is a dynamic and reciprocal system composed of those with whom the individual interacts, including children, siblings, spouse, friends, and neighbors. As one's situational and developmental needs and the environment change, so does the composition of the network (Kahn, 1979).
Some investigators suggest that family and friendship networks are essential to the fact that some frail older adults living in urban America are able to remain in their homes and function successfully while others are not (Bowling & Browne, 1991; Reinhardt, 1996). Others propose that urban elders are at risk for limited involvement in social networks and increased social isolation because of difficulty with transportation, impaired physical health, limited finances, and loss of family and friends (Johnson, 1996; Revicki & Mitchell, 1990). This may also be true for rural elders, particularly those living in frontier areas. However, little research has been conducted to examine stress and social support in this population.
The influence of stress and social support on mortality and physical health has also been well documented in urban elders. Researchers have found positive relationships between increased stress and mortality, positive relationships between in-creased social support and health, and inverse relationships between high levels of social support and stress and mortality in urban elders (Blazer, 1982; Bowling ox Browne, 1991; Broadhead et al, 1983; House, Robbins, & Metzner, 1982; Orth-Gomer & Johnson, 1987; Orth-Gomer & Unden, 1987; Orth-Gomer, Unden, & Edwards, 1988; Strogatz & James, 1986). Yet, the mental and physical health needs of rural older adults have been neglected by health researchers for too long (Ortega, Metroka, & Johnson, 1993; Johnson, 1996). The lack of research on the stress, strain, social support, and physical health of the geographically isolated frontier elderly makes it difficult for nurses to plan the comprehensive care needed by this group of older adults. Such information could enhance the quality of their lives and enable them to remain at home.
Data Collection Instruments
The Stokes-Gordon Stress Scale (SGSS) (Stokes & Gordon, 1988) was used to collect data regarding stress levels, stressful life events, and chronic strains. The SGSS was specifically designed to measure stress in older adults. It lists 104 age-specific situations and events that may lead to stress or strain in the elderly. Respondents are asked to indicate the stressors they are currently experiencing. Scores ranging from 0 to 500 on the SGSS indicate a low level of stress, while those ranging from 501 to 1000 indicate a moderate level of stress. Scores greater than 1001 indicate a high level of stress. The SGSS has content validity, concurrent validity with the Holmes and Rahe Social Readjustment Rating Scale (r = .81, p < . 001), and test-retest reliabilities determined at three times with intervals of 2 weeks for each test period (r = .98, .91., and .90, respectively; p < .001) (Stokes & Gordon, 1988).
The Personal Resource Questionnaire (PRQ85) by Brandt and Weinert (1981) was used to collect data on social support. Part I of the PRQ85 describes 10 situations and asks respondents to identify individuals available to them for assistance. Because it is intended to obtain a description of the social network, there is no range in scores. Part II of the PRQ85 consists of 25 items that measure the perceived level of social support. The items are placed on a 7-point Likert scale. Scores may range from 25 to 175, with a high score indicating a high level of support. Content and construct validity and test-retest reliability (r = .81, p < .001 for Part I; r = .72, p < .001 for Part II) of the PRQ85 have been established using rural families dealing with chronic illness (Brandt & Weinert, 1981; Weinert, 1987; Weinert & Brandt, 1987).
Perceived health status was determined by asking participants to choose one statement indicating their current state of physical health. A score of 1 corresponded with "I think my present physical health is very good," and a score of 5 indicated "I think my present physical health is very poor." The use of a single question to rate health is the most frequently used method to determine self-rated health. Subjectively rated health correlates highly with physicians' evaluations of health (Linn & Linn, 1980; Weinberger, Hiner, & Tierney, 1987).
Potential study participants had to live in an isolated community in the western United States with a population of less than 2,500 or on a farm or ranch; be 64 years of age or older; and able to read, write, or understand English. A convenience sample was recruited from senior centers, religious organizations, and volunteer agencies and through advertisements in newspapers and word-of-mouth referrals.
One hundred and one potential participants were contacted in person or by telephone. After explaining the purpose of the study and subjects' rights, they were invited to complete the three data collection instruments. Ten individuals declined to participate due to illness, and nine were eliminated due to an inability to read, write, or understand English.
Of the 82 individuals who were qualified and agreed to participate, one third received their questionnaires in the mail. The remaining two thirds completed the questionnaires during a home visit from the investigator. The study was approved by the Institutional Review Board for Human Subjects.
Data were analyzed with descriptive statistics, Pearson's productmoment correlation procedure, point-biserial correlation, and analysis of variance.
Fifty women and 32 men who lived in their own homes participated in the study. Their demographic characteristics are shown in Table 1. The communities in which the participants lived ranged in population from 25 to 215 and were separated by mountain ranges and impassable roads during much of the winter. The distance to urban areas with populations of approximately 25,000 ranged from 75 to 123 miles, while the distance to areas of over 50,000 ranged from 150 to 235 miles.
Stress scores on the SGSS ranged from 75 to 2,330 (mean = 1,589.59, SD = 465.71). The majority of elders in this study experienced moderate (n = 23, 28%) to high (w = 32, 39%) levels of stress. Findings also revealed that the older the participant, the greater the level of stress (r = .77, p < .001). Those who were married experienced less stress than those who were widowed (r . = . 71, p <. 01).
The most frequently reported stressful events and chronic strains are shown in Table 2. An additional 25% (n = 21) of the participants selected a fear of their own or a spouse's driving, concern for world conditions, and a change in the behavior of a family member as stressful.
When the level of social support was examined, 21.22% (n = 17) of the sample experienced a high level of support, with scores on the PRQ85 ranging from 116 to 147. Thirty-one percent (n = 26) received scores ranging from 87 to 115, indicating moderate support, and 47.51% (n = 39) had scores of 55 to 86, indicative of a low level of social support. Findings also indicated greater levels of support for women (r b = .73, p < .001), those who were younger (r = .82, p < .01), and those who were married (r ^sub ph^ = .81, p <. 001).
Table 3 shows that the majority of participants had no one to assist them with more than 3 of the 1 0 situations described on the PRQ85. They had to depend on themselves in times of need, when caring for a sick family member, or if they were ill and could not perform their usual activities. Lack of assistance with financial concerns and interpersonal problems was also evident. Table 4 shows the sources of social support for the 43 participants who indicated they had assistance with at least one of the activities on the PRQ85.
Physical Hearth Status
Table 5 displays the self-reported physical health status of the participants. The findings also suggest that older participants (r = -.84, p < .001) and those who were widowed (r , = .81, p < . 01) had poorer health. There was no significant relationship between gender and health status.
An analysis of variance indicated that married women between 64 and 74 years old reported better health (F = 11.74, p < .001), less stress (F = 12.43, p < .001), and greater levels of social support (F = 10.98, p < .01) than married men, widows, and widowers in the same age group and all subjects older than 85 years. Widowers older than 85 years had the poorest health (F = 13.11, p < .001), the greatest stress levels (F = 10.21, p < .05), and the lowest levels of social support (F = 11.01, p<.01).
Because of the nonrandomized, convenience sample used in this study, the results must be interpreted with caution. They are generalizable only to isolated rural White elders. However, the fact that 67% of the sample reported moderateto-high levels of stress, 47.5% indicated a low level of social support, and 58% rated their health as "poor or very poor* suggests that these older adults were at very high risk for increased stress, decreased social support, and poor health. The findings also indicated that widowers older than 85 years may be particularly vulnerable to these phenomena.
Among the most frequently reported stressful life events and chronic strains of the participants were losses from the social support network, decreased social activity, and loneliness. Many of them had lost spouses, adult children, grandchildren, and friends to death. For others, children and grandchildren lived significant distances away and were unable to visit often. The loss of pets added further stress and loneliness to their lives.
Therefore, it is not particularly surprising that the majority of the sample had no one to depend on for assistance in many situations that require support or that the overall level of social support was low. The loss of a driver's license and lack of public transportation in rural areas compounded the sense of isolation and loneliness for many of them. They were unable to visit friends who remained in the area and could not attend the few available social and religious activities. The functions of social support as described by Kahn (1979) were nonexistent for these elders.
Other stressful events and chronic strains reported in this study included diminished physical functioning, illness, decreased self-care abilities, and increased dependence on others. These findings were not unexpected because older adults frequently experience such problems.
It is also not surprising that with this stress and strain, older adults indicated that they did not experience good health. However, it is of concern that they indicated a need for dependence on others when such support may not exist, occurs infrequently, or is not readily accessible.
The results of this study support those of other researchers (Blazer, 1982; Bowling & Browne, 1991; House et al., 1982; Orth-Gomer & Johnson, 1987; Pearlin, 1989; Strogatz & James, 1986) who have found that urban elders with decreased levels of social support and increased stress experience poor health. Like those living in urban and suburban areas, the frontier elders in this study experienced poorer physical health with increased stress and decreased social support.
The finding that married women between the ages of 64 and 74 years reported less stress, more social support, and better health than others suggests that marriage may mediate the effects of stress by providing a social network for women. It is interesting to note that marriage did not have the same effect for elderly frontier men, regardless of age. Individuals older than 85 years, men, and widowers may experience greater losses in their social support networks that lead to increased stress and poorer health than other older adults. For whatever reason, there appears to be age, gender, and marital differences in stress, social support, and physical health for the elderly living in frontier areas of the western United States, and further research is warranted.
IMPLICATIONS FOR NURSING
There are several implications of these findings for nurses working with older adults in frontier areas of America. Nurses should remain cognizant of the relationship among stress, social support, and health. Older clients should be carefully assessed for levels of stress and support and asked to identify specific daily or occasional events that may have resulted in stress or strain. Referrals to appropriate sources of assistance in dealing with these events, such as a local minister, should be considered in the plan of care.
Nurses may also find it helpful to explore ways to increase or strengthen existing social support networks for frontier-dwelling elders. They should be encouraged to maintain frequent telephone contact with friends and family. Large dial telephones, a telephone amplifier, and the availability of a list of frequently used numbers in large print may encourage those who are visually or hearing impaired to use the telephone. Churches can be asked to provide transportation to church and community activities of interest to the older adult. Postal workers are frequently amenable to providing daily contact for these elders, and health care providers can provide a source of support for them. Pets may be suggested as a way to alleviate some of the loneliness resulting from isolation. Many elders use computers or are willing to learn. Through the use of e-mail, they can maintain frequent contact with friends and family 24 hours a day.
The development of easily administered and interpreted questionnaires to assess stress, social support, and perceived health in the older frontier client is needed. Additionally, research is needed to document nursing interventions that are effective in reducing stress, increasing social support, and improving the physical health of older adults living in frontier America. Through such efforts, we may develop a more complete understanding of their needs and ways to meet them.
- Berkman, L.F., & Syme SX. (1979). Social networks, host resistance, and mortality: A 9 year follow-up study of Alameda County residents. American Journal of Epidemiology, 109, 186-204.
- Blazer, D.G. (1982). Social support and mortality in an elderly community population. American Journal of Epidemiology, 115, 684-694.
- Bowling, A., & Browne, P.D. (1991). Social networks, health, and emotional wellbeing among the oldest-old in London. Journal of Gerontology, 46(1), S20-S32.
- Bowling, A., & Charlton, J. (1987). Risk factors for mortality after bereavement: A logistic regression analysis. Journal of the Royal College of General Practitioners, 37, 551-554.
- Brandt, P., Sc Weinert, C. (1981). The PRQ: A social support measure. Nursing Research, 30, 277-280.
- Broadhead, W.E., Kaplan, B.H., Sherman, AJ-, Wagner, E.H., Schoenbach, V.J., Grimsom, R., Heyden, S., Tibblin, G., & Gehlbach, S.H. (1983). The epidemiological evidence for a relationship between social support and health. American Journal of Epidemiology, 117, 521-537.
- Callaghan, P., & Morrisey, J. (1993). Social support and health: a review. Journal of Advanced Nursing, 18, 203-210.
- Cohen, CL, Teresi, J., & Holmes, D. (1987). Social networks and mortality in an inner city elderly population. International Journal of Aging and Human Development, 24, 257-269,
- Hinkle, L.E. (1987). Stress and disease: The concept after 50 years. Social Science and Medicine, 25, 561-566.
- House, J.S., Robbins, C, & Metzner, H.L. (1982). The association of social relationships and activities with mortality: Prospective evidence from the Tecumseh community health study. American Journal of Epidemiology, 116, 123-140.
- Johnson, J.E. (1996). Social support and physical health in the rural elderly. Applied Nursing Research, 9(2), 61-66.
- Kahn, R.L. (1979). Aging and social support. In M.W. Riley (Ed.), Aging from birth to death: Interdisciplinary perspectives (pp. 77-91). Boulder, CO: Westview Press.
- Krause, N. (1987). Stress in racial differences in self-reported health among the elderly. The Gerontologist, 27(1), 72-76.
- Lin, N., Simeone, R.S., Ensel, W.M., & Kuo, W. (1979). Social support, stressful life events, and illness: A model and an empirical test. Journal of Health and Social Behavior, 20, 108-119.
- Linn, B.S., & Linn, M.W. (1980). Objective and self-assessed health in the old and very old. Social Science and Medicine, 14A, 311-315.
- Ortega, ST., Metroka, M.J., 8c Johnson, D.R. (1993). In sickness and in health: Age, social support, and the psychological consequences of physical health among rural and urban residents. In CN. Bull (Ed.), Aging in rural America (pp. 101-116). Newbury Park, CA: Sage.
- Orth-Gomer, K., & Johnson, J.V. (1987). Social network interaction and mortality: A 6 year follow-up study of a random sample of the Swedish population. Journal of Chronic Disease, 40, 949- 957.
- Orth-Gomer, K., & Unden, A. (1987). The measurement of social support in population surveys. Social Science and Medicine, 24, 83-94.
- Orth-Gomer, K., Unden, A., & Edwards, M. (1988). Social isolation and mortality in ischemic heart disease. Acta Medica Scandinavia, 224, 205-215.
- Pearlin, L.I. (1989). The sociological study of stress. Journal of Health and Social Behavior, 30, 241-256.
- Preston, D.B., & Mansfield, RK. (1984). An exploration of stressful life events, illness, and coping among the rural elderly. The Gerontologist, 24(5), 490-494.
- Reinhardt, J.P. (1996). The importance of friendship and family support in adaptation to chronic vision impairment. Journal of Gerontology: Psychological Sciences, 51B(5), 268278.
- Revicki, D.A., & Mitchell, J.P. (1990). Strain, social support, mental health in rural elderly individuals. Journal of Gerontology, 45(b), S267-S274.
- Stokes, S.A., & Gordon, S.E. (1988). Development of an instrument to measure stress in the older adult. Nursing Research, 37(1), 16-19.
- Strogatz, D.S., & James, S.A. (1986). Social support and hypertension among blacks and whites in a rural southern community. American Journal of Epidemiology, 124, 949-956.
- Weinberger, M., Hiner, S.L., & Tierney, W.M. (1987). In support of hassles as a measure of stress in predicting health outcomes. Journal of Behavioral Mediane, 10(1), 19-31.
- Weinert, C. (1987). A social support measure: PRQ 85. Nursing Research, 36(5), 273-277.
- Weinert, C., & Brandt, P. (1987). Measuring social support with the PRQ. Western Journal of Nursing Research, 9, 589-602.
- Wheaton, B. (1985). Models for the stress-buffering functions of coping responses. Journal of Health and Social Behavior 26, 352-364.