The impact of social support and sense of coherence on health-related quality of life among nursing home residents—A questionnaire survey in Bergen, Norway
Introduction
Nursing home (NH) admissions are usually triggered by the inability to continue independent living in the community due to extensive impairment of basic activities of daily living, mainly multiple morbidity or dementia-related symptoms. Even intensive home nursing cannot adequately deal with this. Impairment due to dementia causes the vast majority of admissions to NHs in Norway (Nygaard et al., 2000). NH residents without dementia, who constitute a minority, albeit an important one, concomitantly often have somatic and/or other mental conditions, and coping with multiple morbidity can be stressful. In addition, the residents may also be exposed to other stressful events such as loss of home and relational losses. Any or all of these conditions may influence their health-related quality of life (HRQOL). The ultimate goal of NH care is to assist residents in encouraging functioning and HRQOL. It would therefore be of interest to determine whether social and personal resources influence HRQOL. This knowledge is important to NH staff in elaborating nursing regimens that may improve residents’ HRQOL.
To review previous research on social support, sense of coherence and HRQOL among older people, we searched Medline (1996–2008), PsycINFO (1985–2008) and the Cinahl® Database (1987–2008) using the terms social contact, social network, social support, psychosocial support, interpersonal relation, nursing home, residential care, long-term care, health-related quality of life, well-being and quality of life. Several studies have showed that social support is an important resource for older people in maintaining their functioning (Sherbourne et al., 1992) and well being (Elovainio and Kivimake, 2000, Sherbourne et al., 1992, Wong et al., 2007). Further, social support is associated with physical health (Sherbourne et al., 1992, Travis et al., 2004), mental health (Liu and Guo, 2007, Routasalo et al., 2006) and HRQOL (Fortin et al., 2006, Garcia et al., 2005). The natural source of social support is a spouse, family and friends. A previous study of 13 NHs in Bergen (Drageset, 2004) showed that about 64% of the residents were widowed, and the frequency of contact with family (Bondevik and Skogstad, 1996) and friends (Bondevik and Skogstad, 1996, Drageset, 2002) was mainly monthly. Contact that provides a sense of security and intimacy and a sense of companionship contributes to well being (Farber et al., 1991, Lee et al., 2005). More frequent contact does not mean that the social integrity is better (Seeman et al., 1996), and the quality of social support is more strongly related to well being than is the quantity of social contact (Carpenter, 2002, Chi and Chou, 2001, Pinquart and Sorensen, 2000). People who lack social support are frequently vulnerable to depression (Prince et al., 1997, Tiikkainen and Heikkinen, 2005). The influence of social support on HRQOL among NH residents has received limited attention, although low levels of social support are significantly related to a variety of emotional problems (Bondevik and Skogstad, 1998, Lefrancois et al., 2000, Lin et al., 2007).
Social support refers to the qualitative aspect described as perceived social support, such as the content and availability of relationships with significant others, and social network refers to the quantitative and structural aspects of relationships (Sarason et al., 1990). Weiss (1974) identified and described six categories of relational provisions, each associated with a particular type of relationship. Weiss’ provisions can be divided conceptually into two broad categories: non-assistance-related and assistance-related provisions (Cutrona and Russel, 1987).
The non-assistance-related provisions include the following. (1) Attachment is provided by relationships from which the person gains a sense of safety and security. The absence of such relationships may result in the loneliness of emotional isolation. (2) A network of relationships in which the person shares concerns and common interests provides social integration. The absence of social integration may result in the loneliness of social isolation. (3) Opportunity for nurturance is being responsible for the care of others; absence may result in meaninglessness. (4) Reassurance of worth means a sense of competence and esteem. The absence of support for a sense of worth may lead to low self-regard.
The assistance-related provisions include the following. (5) Reliable alliance is derived from relationships in which the person can count on assistance in times of need. The absence of reliable alliance may result in a sense of vulnerability. (6) Guidance is having relationships with people who can provide knowledge and advice. The absence of guidance may lead to feeling uncertainty and anxiety. Weiss’ framework appears appropriate for understanding the relationships between social interaction and mental well-being, as older people in NHs may experience changes in close relationships, relocation, failing health or the death of a spouse or friends (Mancini and Blieszner, 1992).
Several studies have been based on Weiss’ concept of social support. Cutrona et al. (1986) found that reassurance of worth and opportunity for nurturance significantly predicted physical health for older people, and the provision of reliable alliance and guidance interacted with stress in predicting mental health. Mancini and Blieszner (1992) found that social provisions were important for people 65 years or older living in the community and were met by close relationships with significant others such as family and friends. Felton and Berry (1992) confirmed the importance of fulfilling social provisions among people 63–90 years old staying in the geriatric clinic of a large hospital and how this related with well being. Felton and Berry found that reassurance of worth was most valuable when the source was not family, but reliable alliance was related to family. In a 10-year follow-up study among men and women who were 80 years old in 1990, Lyyra and Heikkinen (2006) found that the risk of death was almost 2.5 times higher among women in the lowest tertile of non-assistance-related social support (comprising infrequent experiences of reassurance of worth, emotional closeness, sense of belonging and opportunity for nurturance) than among women in the highest tertile. In a 5-year follow-up study among people aged 80 years or older living in the community, Tiikkainen and Heikkinen (2005) found negative associations between depression and the subdimensions attachment, reassurance of worth, reliable alliance and guidance and between loneliness and the subdimensions social integration, attachment and reliable alliance. Social support has been shown to be important for emotional and social loneliness among NH residents (Bondevik and Skogstad, 1996, Bondevik and Skogstad, 1998, Drageset, 2004, Drageset, 2002) Thus, social support and its relationships with health and well being among older people seem to be important.
Sense of coherence (SOC) may modify the effect of social support on HRQOL. Antonovsky, 1979, Antonovsky, 1987 examined health-promoting factors in his salutogenic model and developed the concept of SOC to explain why some people become ill when stressed whereas others remain healthy. SOC is defined as “global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence” (Antonovsky, 1987, p. 19). SOC is a general expression of an individual view of the world and includes comprehensibility, manageability and meaningfulness. High SOC suggests that an individual possesses resources that enable him or her to cope with various kinds of stressful life events. Antonovsky (1987) hypothesized that strong SOC would determine whether the outcome of stressful life events would be noxious, neutral or salutary: that is, SOC changes the relationship between strain and stress. SOC seems to have a moderating effect (Eriksson and Lindstrom, 2006), and studies of adults not living in NHs (Albertsen et al., 2001, Anson et al., 1993, Siglen et al., 2007) support SOC being such a moderator.
Social support is another factor that can influence the effect of strain. It has also been hypothesized that SOC again might modify the effect of social support such that people lacking social support might still be able to cope with stress if they have a high SOC. In our context, one might therefore expect that, the higher the SOC, the lower the difference in perceived HRQOL between residents with high and low social support. A study of workers (Feldt, 1997) found such a relationship: good social relations at work heightened well being among subjects with very weak SOC.
Since SOC and social support have also been shown to predict well being among older people (Elovainio and Kivimake 2000), we wanted to investigate whether SOC has any moderating effect on HRQOL among NH residents. To our knowledge, the likelihood of any moderating role of SOC on HRQOL among NHs residents has not been studied extensively.
The main aims were to determine the relationship between social support and HRQOL and to investigate whether SOC modifies the effect of social support on HRQOL.
Section snippets
Design and setting
A cross-sectional, descriptive, correlation design was used. All long-term care residents (n = 2042) from the 30 NHs in the city of Bergen, Norway were potential participants. The study was carried out between 15 January 2004 and 31 May 2005. All participants included provided informed consent. The Western Norway Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the study.
Subjects
All cognitively intact NH residents aged 65 years and older who were
Results
Table 1 presents the demographic characteristics and comorbidity (Functional Comorbidity Index) of the 227 respondents. The mean age was 85.4 years (range 65–102), and the average stay at the time of the interview was 24 months (range 6–119). The residents had 0–6 comorbid illnesses (median 2, mean 1.9, standard deviation 1.2). The most common diagnoses were stroke or transitory ischaemic attack: 67 (29.5%); depression: 40 (17.6%); congestive heart failure (or heart disease): 38 (16.7%); and
Discussion
This study among cognitively intact NH residents found that higher levels of attachment, nurturance and reassurance of worth were associated with higher levels of mental health, social functioning and vitality, respectively, and that lower scores on these social support subdimensions were correlated with lower HRQOL. These findings might suggest that attachment positively affects mental health, opportunity for nurturance improves social functioning and reassurance of worth promotes vitality.
Clinical implications and conclusion
The study indicates that the relationships between NH residents and significant others appear to be an important component of mental health, and the opportunity to provide nurturance for others appears to influence social functioning. Ensuring that nurses arrange for and encourage the residents’ contact with significant others therefore seems to be crucial. However, nurses should be sensitive to residents’ own priorities. Further, nursing care must assist residents in increasing the awareness
Conflict of interest
The authors declare that they have no competing interests.
Funding: Grants from the Norwegian Health Association and Bergen University College supported this research.
Etical approval statement: Mention in 2.1 Design and setting, The Western Norway Regional Commitee for Medical Research Ethics and Norwegian Social Sience Data Services approved the study (REK. Vest nr. 162.03)
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