Content validity and reliability of the Copenhagen social relations questionnaire.

510033 research-article2013

JAH26110.1177/0898264313510033Lund et al.

Article

Content Validity and Reliability of the Copenhagen Social Relations Questionnaire

Journal of Aging and Health 2014, Vol. 26(1) 128–150 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264313510033 jah.sagepub.com

Rikke Lund, MD, PhD1, Lene Snabe Nielsen, MSc Public Health1, Pia Wichmann Henriksen, MSc Psychology2, Lone Schmidt, PhD, DMSc1, Kirsten Avlund, PhD, DMSc1,2,3, and Ulla Christensen, PhD1

Abstract Objective: The aim of the present article is to describe the face and content validity as well as reliability of the Copenhagen Social Relations Questionnaire (CSRQ). Method: The face and content validity test was based on focus group discussions and individual interviews with 31 informants. Another 94 men and women participated in an 8-day test–retest analysis. Results: Informants generally expressed that the questions and response categories were relevant and easy to understand. Themes on structure of social relations, social support, and negative aspects of social relations emerged clearly from the interviews. Two additional themes not covered by CSRQ on dynamics and reciprocity of social relations were identified. Discussion: CSRQ holds satisfactory face and content validity as well as reliability, and is suitable for measuring structure and function of social relations including the negative aspects among middle-aged individuals.

1University

of Copenhagen, Denmark of Southern Denmark, Copenhagen 3Aarhus University, Denmark 2University

Corresponding Author: Rikke Lund, MD, PhD, University of Copenhagen, Faculty of Health Science, Oster Farimagsgade 5, P.O. Box 2099, Copenhagen, DK-1014 K, Denmark. Email: [email protected]

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Lund et al. Keywords social factors, families, living arrangements

Introduction There is substantial scientific support for the health protective effects of social relations, in general populations and in patient groups. This has been studied for a large variety of health outcomes, for example, cardiovascular disease (Barth, Schneider, & von Kanel, 2010; de Vogli, Chandola, & Marmot, 2007; Lund, Rod, & Christensen, 2012; Rozanski, Blumenthal, & Kaplan, 1999), infectious diseases and inflammation (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997; Kiecolt-Glaser, Gouin, & Hantsoo, 2010), cancer survival (Pinquart & Duberstein, 2010), mental health problems (Lund et al., 2009; Oxman, Berkman, Kasl, Freeman, & Barrett, 1992), self-rated health (Kumar, Calvo, Avendano, Sivaramakrishnan, & Berkman, 2012), and mortality (Holt-Lunstad, Smith, & Layton, 2010). Of special interest when regarding aging, well-functioning social relations are also associated with lower risk of development of functional (Avlund et al., 2004; Mendes de Leon, Glass, & Berkman, 2003; Nilsson, Avlund, & Lund, 2011) as well as cognitive decline (Dickinson, Potter, Hybels, McQuoid, & Steffens, 2011). Despite the overall agreement on health protective effects of social relations, research in this area has been criticized for the large heterogeneity in definitions and assessments of social relations, which weakens the understanding of the concept as one well-defined entity. This presumably can partly be explained by the high complexity of the concept covering a number of related aspects, the different backgrounds of researchers in this field (public health, epidemiology, medicine, psychology, anthropology, and sociology) and the different choices of what to cover in the specific research project. However, broadly spoken social relations are usually defined by the structures of an individual’s social life (quantitative aspects such as network size, diversity, and contact frequency) and by their functions (qualitative aspects such as emotional and instrumental support; Due, Holstein, Lund, Modvig, & Avlund, 1999; Uchino, 2004). The structure of social relations is often described as the framework through which the qualities of social relations flow (Berkman & Glass, 2000). The quality of social relations can be measured as perceived (the expectations of support in case of need) or received support (the actual support experienced in a specified situation). Most research in this area has focused on the positive qualities of social relations, whereas the inevitable negative aspects have received less attention. Furthermore, it might be important to distinguish different types of strain from social relations such as conflicts, demands, worries, disappointments,


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and envy as they may differently influence health and aging. The ability to distinguish between the different sources of support may also be important, because they serve different functions and because identification of these differences will aid in intervention planning (Glass, Mendes de Leon, Seeman, & Berkman, 1997; Uchino, 2004). As mentioned, a large variety of instruments have been developed to assess social relations ranging from instruments focusing primarily on the structural aspects (also sometimes called social integration) to instruments focusing on the qualitative aspects in some cases with a high level of complexity. The social network index (SNI) is a classic example of a measure of social integration based on information on marital status, contact with family and friends, participation in voluntary work, and church organizations (Berkman & Syme, 1979). Considering the functional aspects of social relations, detailed measures have been developed, among those the Social Support Questionnaire including 27 items intended to quantify the dimensions of perceived availability of and satisfaction with social support (Sarason, Levine, Basham, & Sarason, 1983). Very detailed measures are space consuming and, often, not appropriate in larger scale population studies. Therefore, shorter instruments covering structure and function at a less detailed level have been developed, one example is the Close Persons Questionnaire (Stansfeld & Marmot, 1992). The lack of overall agreement on how to measure social relations in health research (O’Reilly, 1988; Uchino, 2004) might also be due to real differences in what are the most relevant aspects of social relations in specific cohorts. For example, there are potentially large cultural differences in what defines well-functioning and sufficient social relations (Uchino, 2004), although of course similarities are also suggested (Kumar et al., 2012). In addition, social relations change in structure and function over the life course as our requirements for support from the social relations change with changing needs and resources (Antonucci & Akiyama, 1987; Carstensen, 1995). All in all, a gold standard for measuring social relations in health research is most likely not a possibility. It is a challenge to capture a broad concept as social relations by a single instrument, and consequently decisions on what to include must be guided by a conceptual framework, the research questions as well as the context, for example study population, length of questionnaire, and so on. Based on a careful literature review of existing instruments, we developed the Copenhagen Social Relations Questionnaire (CSRQ) in 2000 as a measure suitable for middle-aged (35-65 years) men and women living in a Scandinavian welfare state. We based the instrument on the conceptual model presented by Due and colleagues (1999), covering structural as well as functional aspects of social relations including negative qualities of social


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relations. Hereby, CSRQ is placed among the shorter instruments intended for population studies assessing structure and function. Furthermore, following the recommendations by Glass and colleagues (1997) and Uchino (2004), we wanted to cover a number of different roles in the social network to distinguish the health effects of different sources of support or negative interaction. Regarding the structural aspect of social relations, CSRQ was designed to focus on contact frequency and diversity. With respect to the functional aspects, we chose to focus on perceived social support (the expectation of support to be available if needed). However, the questions on negative qualities of social relations were formulated closer to the tradition of received “support” as, for example, conflicts or demands are not expected but actually experienced (see Table 1 for the precise wording). When developed, any instrument needs to be evaluated for validity and reliability to test its precision, usefulness, and relevance. Validity of an instrument can be assessed in various ways, but overall, it states “how well it measures what it purports to measure” (Nunnally & Bernstein, 1994). Lack of validity leads to systematic error (Grønvold, 1996; Nunnally & Bernstein, 1994). One important type of validity is the extent to which it is documented that the content of a measure is relevant (Grønvold, 1996). Content validity is usually established through a combination of a literature review including the review of possible existing questionnaires and interviews with “specialists” within the area of interest. Face validity can be considered one limited aspect of content validity and is usually assessed after the instrument is constructed. “It is concerning an inspection of the final product to make sure that nothing went wrong when transforming plans into a completed instrument”(Nunnally & Bernstein, 1994). The aim of the present article is to describe the face and content validity of the CSRQ used in Copenhagen Aging and Midlife Biobank (CAMB) assessed by individual interviews and focus group discussions (FGDs). Furthermore, the reliability of each item based on an 8-day interval test–retest analysis will be assessed.

Material and Method The analyses in the present article are based on two data sources: (a) the population for the face and content validity test of CSRQ based on FGD (n = 21 participants) and individual interviews (n = 10); the informants were recruited specifically for this study and matched to the characteristics of CAMB (the informants participated in either FGD or an individual interview); and (b) the population (n = 94) for the test–retest analysis of CSRQ, recruited specifically for the reliability test. The CSRQ was developed in 2000 and has been used in several Danish population based surveys during the past 12 years, most


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Table 1. Copenhagen Social Relations Questionnaire (CSRQ) 42 Items. Structural aspects Do you have children? (biological, adopted, partner’s children, or foster children) If yes, how many? Do you live alone? (yes/no) Who do you live with? (all of the time or most of the time) (spouse or partner, your own children, children that are not your own, or other(s)) How often are you together with any of the following people, who you do not live with? (several days a week, once a week, 1-3 times a month, less than once a month, never, or have no)a How often do you have contact with any of the following people, without seeing them? (e.g. phone, letters, email, or sms) (several days a week, once a week, 1-3 times a month, less than once a month, never, or have no)a Functional aspects Support Would any of the following people help you with daily practical matters if necessary? (always, often, sometimes, seldom, never, or have no)b Can you talk with any of the following people, if you need support? (always, often, sometimes, seldom, never, or have no)b Strain In your daily life, do you experience that any of the following people demands too much of you? (always, often, sometimes, seldom, never, or have no)b In your daily life, do you experience that any of the following people seriously worry you? (always, often, sometimes, seldom, never, or have no)b In your daily life, do you experience conflicts with any of the following people? (always, often, sometimes, seldom, never, or have no)b aOne item for each of the following: children (your own or partner’s), family, friends, colleagues (outside of work). bOne item for each of the following: partner, children (your own or partner’s), family, friends, colleagues (outside of work).

recently in CAMB. The reliability test was performed in 2000 and the face/ content validation took place in 2009-2011. A validation study was initiated already at the time of development of CSRQ in 1999. Unfortunately, the original tapes and transcriptions were lost before they were analyzed and funding for a new validation study was not secured until 2009.

Face and Content Validity Sampling Sampling in qualitative research is usually done in a stepwise way, including more data from one group or another depending on what extra material


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is needed to answer the research question effectively (Malterud, 2001). We used a purposeful sampling strategy seeking maximal variation (Patton, 1987) according to age, gender, ethnicity, cohabitation status, and socioeconomic status to match the characteristics of the population selected for CAMB and because social relations are known to vary with these sociodemographic variables (Ajrouch, Blandon, & Antonucci, 2005; Kumar et al., 2012; Shumaker & Hill, 1991). During the ongoing data collection, we sought to fulfill this strategy by snowball sampling meaning that the initial subjects were asked to identify people in their network with characteristics that until then had been underrepresented among informants (i.e., living alone, male gender, high socioeconomic status). Three FGDs were conducted: one at university campus, one in a private home, and one at a workplace in suburban Copenhagen. The sample consisted of 15 women and 6 men, with the mean age 55.1 years (range = 38-69). In total, 19 informants lived with a husband, wife, or partner; one was in a relationship but lived alone; and one was a widow/widower. A majority of the informants was from lower social classes. The FGDs revealed a wide variety of important points concerning social relations as the participants inspired each other to talk about and consider the topics of the discussion. However, a well-known drawback of FGD is the reluctance among participants to talk about more difficult and personal issues (Krueger & Casey, 2009), such as in this case, the negative aspects of social relations. Consequently, we chose to supplement the FGDs with individual interviews to be able to better investigate the validity of these items in CSRQ. Ten individual interviews were held at the workplace or in the home of the interviewees or at the university campus. The sample consisted of 5 women and 5 men, with the mean age 55.3 years (range = 50-58). In total, 6 lived with a husband, wife, or partner, and the majority belonged to the higher socioeconomic groups. The characteristics of the informants for the FGDs and interviews are shown in Table 2.

Questions for FGD and Individual Interviews In accordance with the chosen conceptual model for social relations (Due et al., 1999), a list of questions for the FGDs and individual interviews was developed covering the three main themes included in CSRQ: (a) structure of social relations, (b) social support, and (c) negative aspects of social relations (see Table 3). The list of questions developed over time as a consequence of the previous interviews, but the list of questions listed here is the core of questions posed during interviews/discussions.


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Table 2. Characteristics of the Participants in Focus Group Discussions and Single Interviews. FGD (n = 21) Single interviews (n = 10) Gender Women Men Age (years) 60 Cohabitation status Live with spouse/partner Divorced/widowed Other (live alone but in a relationship) Occupational social class I. Professionals, executives, and large-scale self-employed II. M edium-level white-collar and medium-scale self-employed III. Low-level white-collar and smallscale self-employed IV. Skilled workers V. Unskilled and semiskilled workers VII. Not possible to classify, for example, housewives Location of the FGD/interview University campus (workplace to all FGD participants) Private home Staff room at a hospital Workplace

15 6

5 5

2 14 5

— 10 —

19 1 1

6 3 1

1

2

3

4

6

1

3 4 4

1 1 1

8

2

6 7 —

4 — 4

Procedure All FGDs and interviews began with a brief presentation of the project, and the informants were subsequently asked to fill in the 42-item questionnaire on social relations (see Table 3). Then all sessions continued with the question “What is your immediate impression of the questionnaire?” and subsequently each of the three themes were introduced and left again when the participants started repeating what had previously been stated by others or by themselves. When introducing each of the three themes, the wording from the CSRQ was carefully avoided to facilitate a spontaneous conversation. All participants in


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Table 3. List of Questions Used as a Guide in the Focus Group Discussions and Individual Interviews. Interview question

Notes

I would like to hear a little about your/Your firsthand impression of the questionnaire. What is your immediate reaction to the questionnaire?

If the informants are in doubt, what is meant by the question, you can, for example, ask the following: Were the questions easy to understand? Did any of the questions miss a response possibility in your opinion? What about the questions worked out well and less well? Be aware if the different social roles emerge

I will now move toward the topic of social relations. Who are you/You in contact with on weekdays and on weekends? Do you/You have more frequent contact with some of these people than others? What is the reason for you/You having more frequent contact with . . . (the type of people that are mentioned)? What is the reason for you/You having less contact with . . . (the type of people that are mentioned)? I have now gained an impression of who are in your/Your network and why you/You are in contact with them. Would you/You describe situations where you/ You have been in need of help or support from people in your/Your network? Who did you/You contact? What help/support did they provide you with? We now have been talking about situations where social relations provide positive support. Can you/You describe situations where the social network may be straining? How do you experience them as straining? Can you/You think of other situations, when social relations are not just a positive experience? Do you have important information about the social relations that you find relevant and that you do not think has been touched on during the discussion/interview?

These questions give an impression of the type of people in the informant’s life and how often they are in contact with them. The questions also work as a transition to the following question on the functional aspects of social relations Be aware to pose further questions if the help/support they report has the similar characteristics

Be aware if the informants mention different types of strain

the FGD were encouraged to participate actively. The FGDs lasted between 60 and 90 min and the individual interviews lasted between 35 and 60 min. L.S.N. was the moderator of all FGDs, and R.L. was assistant moderator on two of the three FGDs. L.S.N. was conducting all individual interviews with R.L. as


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an observer on two of these. The moderator of the FGDs facilitated the discussion with all participants actively contributing. All FGDs and individual interviews were transcribed verbatim within the following 24 hr by L.S.N.

Analysis All transcripts were treated as one single data set including FGDs and individual interviews. The transcripts were analyzed with Template analysis as described by King (2004) and Crabtree and Miller (1999). Initially, a list of codes was defined based on the conceptual model (the initial template). Once an initial template was constructed, we worked systematically through the full set of transcripts, identifying sections of text that were relevant to the project’s aims and marking them with one or more appropriate codes from the initial template. In the course of this, inadequacies in the initial template were revealed, requiring changes of various kinds. Through this process, the template developed to its final form (Crabtree & Miller, 1999; King, 2004). To ensure consistency in the coding, as well as to increase validity of the analysis (Malterud, 2001), four of the researchers (L.S.N., R.L., U.C., and P.W.H.) independently coded three of the transcripts (one FGD and two individual interviews) and discussed the coding until consensus was obtained. Furthermore, the coding and the analysis were discussed in detail among all involved authors and an extended group of researchers. Based on these thorough discussions and analytical decisions, L.S.N. coded the remaining transcripts. Quotations with discrepancy in the encodings were discussed until consensus was reached. Quotations for this article were translated from Danish into English and as recommended by Meadows and colleagues with an emphasis on semantic equivalence rather than on direct translation (Meadows, Bentzen, & Touw-Otten, 1996). The final thematic template including the three main themes, the emerging additional themes as well as a theme concerning the immediate assessment of CSRQ is displayed in Table 4.

Reliability Test To test the reliability of CSRQ, we performed a separate test–retest of each item with an 8-day interval (n = 94), and weighted kappa values were calculated. Participants were recruited at three different places: (a) evening classes for people with shoulder neck and back problems (n = 16), (b) patients at a physiotherapy rehabilitation center (n = 24), and (c) employees at the home care service in the Municipality of Copenhagen attending a course on appropriate lifting and cleaning techniques to avoid later back and joint problems


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Lund et al. Table 4. The Final Thematic Template. Major themes

Subthemes

General assessment General assessment of the questionnaire Structure Type of relation Contact frequency Type of contact Social support Emotional support Instrumental support Negative aspects Conflicts Excessive demands Worries Additional themes Dynamics in social relations Reciprocity

Relevance, immediate comprehensibility (including language), response categories Partner, family, friends vs. acquaintances, neighbors and colleagues Close and peripheral relations, contact frequency and duration For example, contact by electronic media Close and peripheral social relations, selection in who to turn to Close and peripheral social relations, who does not ask for help? For example, definition of conflicts, conflicts with family, conflicts with friends For example, social ground rules, close and peripheral social relations, how to back out, demands on yourself Reasons for worries, different types of worries The structure changes, contact frequency, change in social roles over time, fewer conflicts Close and peripheral social relations, balance in social exchange, lack of reciprocity

(n = 54). As questions on coping with back pain also were part of the test– retest, there was a focus on people at risk of, or with already present, back and other joint problems. The age ranged from 21 to 78 years (M age = 40.2 years) and 29% were men and 71% women.

Results Face and Content Validity General assessment of the questionnaire. In general, the informants agreed that the CSRQ covers relevant aspects of social relations in a simple and useful


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way among others due to the role of specific items on different types of social support (emotional, instrumental) and relational strain (conflict, demands, worries). Furthermore, the language used was clear and the number of response categories satisfactory: “I think the questions were simple and useful . . . I do not have the feeling that relevant aspects of my social relations are not covered by the questions” (woman, 58 years). “It was very simple. Especially, because it was differentiated (into partner, children, family, friends and colleagues)” (woman, 55 years). However, a few informants mentioned that they would have preferred the question on conflicts to be more specific. A male informant said, “In relation to conflicts I had this doubt whether it was deeper conflicts or these everyday disagreements?” (man, 54 years). In summary, the face validity of CSRQ is judged to be satisfactory based on the general positive assessment by the informants, although the question on conflicts with social relations gave rise to some uncertainty on what exactly was meant by “a conflict.” Structure of social relations Type of relations. Across informants, the social network consisted of partners, biological children, partner’s and adopted children, grandchildren, partner’s and own siblings, and their families, parents (biological and foster), friends, acquaintances, colleagues, and neighbors. However, the number of the above-mentioned categories as well as the number of persons within each category varied from informant to informant resulting in a great variety in size of the informants’ network. Spouse/partner, children, siblings, and parents were categorized as family. Together with friends, they were major representatives in the informants’ social network: “I have two big categories of persons represented in my network. It is friends and it is family. It is hard for me to say which one of the categories I have most frequently contact to” (woman, 56 years). Close friends played a central role for informants with small families or limited contact with their families and were perceived as family members as they performed some of the supportive functions that family typically does: “I have mainly contact with my friends. They are very important to me because my family is small and we do not have close relationships. I call my friends family because I have known them for a long time and the relations are strong. They support me and will never disappear.” (Woman, 58 years) The distinction between friends and acquaintances was evident. Friendships were based on trust and confidentiality to a limited number of close friends and a larger number of less close friends: “Friends are people you open up to and are confidant with . . . Acquaintances are nice people with whom you can spend an afternoon or evening together with but you will not


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turn inside out” (woman, 55 years). Social relations with acquaintances were characterized as peripheral relations held together by common interests, experiences, or understandings. “Those I play music with in the orchestra are not people I am close to. They are not the ones I would turn to in times of crisis. They are just those I feel good with, when we are together—and we have a sense of community around making music together.” (Woman, 67 years) There was no consensus about the role of neighbors and colleagues as either friends or acquaintances in the social network. For neighbors, the spectrum of quotations ranked from “they have had a major impact on my life. They have become friends” (woman, 58 years) to “neighbors are not close contacts. They are not someone we invite over. We talk over the hedge” (man, 54 years). Among informants with labor market attachment, it was not unusual to catch up with colleagues outside working hours. However, the presence of colleagues in the informants’ network was naturally to a great extent dependent on the informants’ job position: “Given that I am a principal of school I have chosen not to be socially involved with my colleagues. I cannot drink red wine with a colleague on Fridays and perhaps convene him for a meeting on the following Monday . . . This could give rise to a loyalty conflict and rouse hostile feelings among the other employees.” (Man, 54 years) Contact frequency. A large diversity in contact frequency was observed between the informants. The informants were in frequent contact with or intended to be in frequent contact with close family members together with friends and acquaintances with whom they shared common interests, for example, a tennis partner or the riders from the bicycle club: “My mother and her three daughters have just been in Berlin for an extended weekend. We see each other very often. However, I probably see my friends more often. I have three very close friends whom I talk to once a week—at least—and catch up with as well.” (Woman, 56 years) Contact with relatives was less frequent, whereas contact with colleagues for some informants was restricted to working hours. Even though the informants described that they had the highest contact frequency with persons in their closest network, it was also stated that contact frequency is not necessarily an indication of how close or peripheral a relationship is: “I have friends that I see once a year and I have friends that I catch up with 4 times a year. But they are still friends. Close friends” (woman, 67 years). Type of contact. Different types of contact forms were mentioned. The informants preferred face-to-face contact with persons in their close social relationships. However, telephone conversations and other electronic com-


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munication were also used for updates or confirmations of appointments with a child or friend: “I use email to coordinate a meeting. Who will be where and when? Are we at your place or at my place?” (man, 54 years). The informants chose between the different forms of electronic communication (telephone conversations, emails, short message services [sms], and Facebook) depending on what to be provided to whom: “You give a call if it is about something personal. You cannot have that dialogue on sms or mail . . . It is also something about hearing the voice. You can write “I am fine” but if you call you can hear that it is not the truth.” (Woman, 49 years) In summary, the validity of CSRQ concerning structure of social relations appears to be supported by the analysis. The social roles represented in CSRQ are spontaneously mentioned by the informants, that is, partner, children, other family members (predominantly siblings and parents), friends, and colleagues. Furthermore, informants describe a broad variation in contact frequency and type of contact, which is also reflected in the CSRQ items and response categories. Although informants did not call for additional social roles in the questionnaire, the interviews and discussions revealed that especially people with whom you share a common interest (but who are not your close friends) and neighbors play an important role in many respondents network. In addition, the heterogeneity in size of networks became evident from the interviews. Social support Emotional support. The informants’ main sources of social support came from persons in their close network. Particularly, support from a spouse or partner was significant. However, for informants not having a spouse or partner, other persons from close relationships could replace his or her support: “Given that I live alone I need to have some other persons to talk to about my problems” (woman, 58 years). However, there was also a selection in source to emotional support within the close network depending on the nature of the problem: “Before I contact someone in my network to talk about my worries I evaluate whether it is appropriate to contact a close colleague, friend or a member of my family” (woman, 50 years). Despite strong social ties to children and parents, several informants mentioned that they would not bother them with their personal problems: “If I have any problems I do not call my mother. You give your mother a call when you have good news. My children feel the same way. Parents should not be concerned about their children” (woman, 53 years). Basically, the informants did not contact the peripheral network for emotional support. They did not find it appropriate to mix private and working spheres. However, in some cases, colleagues were supportive in job related situations: “I have two colleagues I talk to when I have job related


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problems. But I do not talk to them about private things for example my desire to find a husband. I only use them in job related situations” (woman, 56 years) Instrumental support. The informants agreed that practical assistance was mainly provided by close family members and friends: “I am sure that friends and relatives will assist in whatever practical matter, especially the kids” (woman, 67 years). However, some informants also mentioned acquaintances and neighbors as candidates for practical assistance: “We (neighbors) help each other. (When someone is on vacation) we look after each other’s cats. We water each other’s flowers” (woman, 58 years). However, not all informants got instrumental support from their social network mainly because they preferred to do the things themselves or were not good at asking for help: “ . . . I am not good at asking for help and therefore I have not received help. But I have asked for help now (to fix the beech wood in the garden), and I got it” (woman, 56 years). In summary, the validity of measures of social support in CSRQ also appears to be supported by the analysis. The informants report to receive support from a number of different types of social relations, although predominantly from their closest relations; therefore, the possibility of reporting support from different social roles is meaningful, and the chosen social roles are spontaneously mentioned by the informants. In addition, the types of support (emotional and instrumental) seem relevant. However, reporting low social support could be due to either low availability of support asked for or the informant being reluctant to ask for support in general. CSRQ is not able to distinguish between these two causes of low score in social support. Negative aspects Conflicts. Most informants experienced conflicts in their social relations. However, conflicts covered a spectrum from everyday disagreements to severe conflicts where contact was hampered or completely stopped. “The only one I have had a conflict with does not exist anymore (in my network). It is the person I was married to for 11 years . . . We had a conflict that ended in a ferocious divorce. We have no contact now. There are also these disagreements. A friend and I own a house together and sometimes we have to fix something on this house. It is not a conflict that last forever or an emotional conflict. It is a conflict of practical nature. You cannot avoid them.” (Woman, 56 years) Conflicts within the family were special in two ways. First, they were intrusive and emotionally stressful, especially conflicts with a partner: “A marital conflict differs from a conflict with others because a marital conflict hits your deepest feelings. And that is probably what hurts mostly” (man, 54 years). Second, the informants were willing to compromise to maintain the contact


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because conflicts in the family have consequences for several persons: “We have some problems with my sister. She cannot control herself. She creates much trouble in the family. But for my mother’s sake and as long as my mother is alive we invite my sister for celebrations” (man, 56 years). The informants perceived that conflicts with friends could also occur. However, these conflicts were not as stressful as conflicts within families. In addition, it was easier to opt-out of the relationship: “Relatives are special in the sense that you have them for good and bad. You choose your friends and they are for the good. If not, of course you can decide not to see him again” (man, 56 years). Excessive demands. Several informants stressed that being part of a social network implies the issue of demands. These demands work as a set of rules for the relation and they can be more or less implicit: “In a friendship you harmonize mutual demands and expectations, without expressing it directly . . . it’s just something that works out. And when an imbalance occurs, that can be the reason for the friendship to cease” (woman, 50 years). “Of course the family makes demands on me, and I try to cope with them, the best I can . . . As well as I make demands on my children, friends, my closest ones, just as well they can make demands on me.” (Man, 52 years) Informants primarily experienced excessive demands in terms of expectations that they were not able to meet or did not want to meet: “My son expected to spend more time with me than we did . . . I felt that he was sad, that we did not spend that much time together. He needed me more than there were available hours in the day . . . but I was time constrained due to work and doing other things.” (Man, 54 years). “When an acquaintance was divorced she crossed my line. I felt I did not know what to say and do because I did not know the person well enough. It was a requirement for an empathy that I could not meet at all.” (Woman, 56 years) “With friends you can take a lot. With acquaintances you can take fewer things. When an acquaintance uses you to unload on—whether it is practical assistance or personal problems—you get to a point where it is too much. You are not close enough . . . I think it is of great importance what type of relationship it is.” (Man, 56 years)

Informants with and without excessive demands agreed that it was important to say “no” and stand your ground if it becomes too much: “I am a plumber. It is important to say no when you have a huge family and in laws. I have told them that the only persons I help with plumbing and artisanal tasks are my children. There are many in the family who cannot understand me. But I still see them.” (man, 47 years) “Sometimes I have had to say “no.” A friend of mine got divorced and had to move. Suddenly it became too much. I could not have time off from work without spending it with her. I had to say


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that I understood that it was a hard time for her but I also had to take care of myself and my own . . . We had at talk about it and she understood me. Since that time there have not been any problems.” (Woman, 58 years). Worries. Worries were described as an uncertainty about in what direction things will go for people within the social network: “My daughter has been seriously ill and I am often concerned about her . . . I am happy when she gives a call but I can also have this sinking feeling when the telephone rings” (man, 52 years); second, their parents’ old age: “I am concerned about my parents because my father is getting old. I am concerned whether they can manage. Will they be unhappy? Will one of them have to live in a nursing home? When will I get a call from my mum telling me that my dad is in hospital after a collapse?” (Woman, 56 years) In addition, several informants mentioned that they also thought of and were aware of friends and neighbors having problems. However, these kinds of worries were not comparable with worries for close family members. “My sister means a lot to me. That is for sure. It is easier for me to put my friends’ problems away because they have a family and close relationships. But if something happens to my sister and her family then I would think about it a lot.” (Woman, 58 years). In summary, the items of negative aspects of social relations in CSRQ appear to have a good validity. Worries and demands were mentioned spontaneously in the discussions and interviews. In general, negative interactions were experienced worse when they involved the closest social relations but were experienced with several types of social relations. This underlines the reasonable in including the different social roles as separate items. The topic on conflicts was relevant to the informants, but there was less agreement on when a conflict/disagreement was “bad” enough to be considered. Furthermore, parents were explicitly mentioned as a separate role in connection with worries. The CSRQ does not cover this important social role separately. Additional themes. In addition to the three main themes, two additional topics not covered by CSRQ evolved from the interviews and discussions, namely (a) the dynamic nature of social relations and (b) the issue of reciprocity in social exchange. The dynamic nature of social relations. Structure and function of the relations changed over time. Some persons had entered the network and others had disappeared: “Social relations are not stable over time—at least not all social relationships. It is not given that you have the same friends from age


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12 until you die. People enter and leave the network for a reason” (man, 58 years). Besides changes in network structure, it was also evident that changes within the network occurred. Some persons got closer to the focal person and others moved away from the focal person: “Periodically I have had close contact to my sister and at other times to my brother. But after our parents died my sister, brother and I have all had very close contact” (woman, 56 years). A central aspect of social relations’ function had also changed over time. A common feature was that conflict-ridden relationships became less common with age because those relationships were opted or conflicts were avoided: “Conflict-ridden relationships become less pronounced with age. I do not collect them. But I also think that you mellow with age. You know who you are and who the others are . . . You have a lifetime of experience and know what is worthwhile to spend time and energy on and not.” (Woman, 58 years). In summary, an important characteristic of social relations is that they inevitably change over time for good and for bad. This quality is important to be aware of when measuring social relations. Reciprocity. When talking about the availability of instrumental and emotional support, the informants focused on the importance of reciprocity in social relationships: “When they (friends) experience something difficult, then I’ll be there. I think it is part of a good friendship . . .you do not ‘pay back’ immediately, but you mutually exchange (support) along the way” (woman, 55 years). They also focused on the risk of contact ceasing if reciprocity was lacking–particularly in nonfamily related social relations: “You would be disappointed and take up for consideration whether you would help on another occasion if you have helped a person several times and get a “no” when you yourself ask that person for help. However, in close social relations you can better accept a “no” and wait for the other person to help you some other time when you need it. But in more peripheral relations the contact might cease.” (Man, 54 years) A female informant had already experienced contact ceasing because there was no reciprocity in the relationship: “I have had some huge conflicts with two friends whom I do not see anymore. We were not good for each other. I was the prime mover and had to compromise all the time . . . There was no mutual respect and caring.” (Woman, 58 years) In summary, another crucial characteristic of well-functioning social relations is mutual exchange of support. Furthermore, this exchange was expected to a different degree from different social roles in the network. There is however a subtle distinction between the experience of an adequate reciprocity in


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a relation and the feeling of too many demands from social relations. However, to be able to distinguish the characteristic of reciprocity from the experience of demands, issues on role specific reciprocity should be developed and included in future versions of CSRQ.

Reliability Test Reliability of CSRQ was judged according to the recommendations by Landis and Koch (Landis & Koch, 1977).The analyses of test–retest reliability showed that 41% of the items had substantial to almost perfect agreement (kappa values from .65-.97) and the rest showed moderate agreement (kappa values from .41-.60). Only one item, experience of conflicts with friends (kappa = .35), showed slight agreement. In general, items concerning visual contact frequency and support/ strain from partner and children were scoring the highest kappa values reflecting a higher consistency in reporting structural and functional aspects of the closest social relations. Unsurprisingly, the most simple questions and questions most unlikely to real change over an 8-day period showed the highest kappa values, for example, “do you live alone?” (kappa = .97). In summary, the reliability of CSRQ appears to be good.

Discussion The main results of the present study suggest a satisfactory face and content validity, as well as good reliability of the CSRQ. Informants generally expressed that the questions and response categories were relevant and easy to understand. The social roles included in CSRQ (partner, children, other family, friends, and colleagues) were mentioned spontaneously by the informants during discussions/interviews, and they did not explicitly call for additional categories in their immediate response to the CSRQ. Furthermore, the participants provided data that supports the three themes on structure of social relations, social support, and negative aspects of social relations that were part of the conceptual model. Our analysis showed that CSRQ is meaningful in adult life (age = 38-69 years) and to men and women. The CSRQ has several additional strengths. First of all, the instrument is developed on the basis of a conceptual framework (Due et al., 1999) that secures the theoretically based selection of aspects to be included in the instrument. Second, the focus on several predefined social roles allows analyses of role specific exposures as for the development of a measure of diversity. Third, the detailed information on negative aspects of social relations as well as of social support allows for studying aging and health effects


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of positive and negative aspects of social relations as well as their possible interaction. This is important to understand the possible alleviating effects of support when exposed to strain from social relations according to the stressbuffer theory (Cohen & Wills, 1985), or the amplified effects of lack of support and high degree of negative social exchange. From the interviews, it became evident that CSRQ does not cover two specific social roles: neighbors and acquaintances. Neighbors could easily be included as an additional social role in CSRQ, even though they play very different roles in people’s life, ranging from the very close relation (where they are labeled as friends) to absolutely no contact at all. It is more difficult to include a meaningful social role covering acquaintances because of the heterogeneous nature of this type of contact. However, this type of relation was mentioned in almost all FGDs and some individual interviews, stressing its importance. The development of meaningful items, covering this social role, would without doubt add valuable information. The analysis pointed at imprecision on what was meant by “conflicts.” The intention was to cover the more severe types of conflicts but was described by respondents with very different characteristics ranging from severe conflicts to everyday disagreements. This calls for more detailed testing on how to measure severe conflicts in a meaningful way. Furthermore, the analysis suggested that low levels of support could either be due to the reluctance to ask for support or low possibility of getting support when needed. A few informants clearly expressed that asking for help was something they very seldom did. In this case, low levels of social support might also reflect certain personality traits rather than the network being unavailable for support provision. A response category with the option of “I do not ask for support” could potentially make up a solution to this problem and thereby avoid misclassification of people with low levels of support due to their own reluctance to ask for it. Two additional themes were identified during the analysis, namely, the issue of reciprocity in contact and support and the dynamic nature of social relations over the life course. Reciprocity in social support has been suggested to be especially health protective over and above the effects of support received (Brown, Nesse, Vinokur, & Smith, 2003). This indicates that the inclusion of items concerning role specific reciprocity or perceived balance of provided and received support would improve the instrument, as several informants explicitly mentioned this imbalance. The dynamic nature of social relations is described by the convoy theory stating that social relations can be described as a convoy where some network members follow us for long periods, perhaps all life, while others are there for shorter periods whereupon they disappear forever or for a time period (Antonucci & Akiyama, 1987). In


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addition, the socioemotional selectivity theory focus on dynamics in social relations stating that with increasing age, people tend to focus on a narrower and less demanding network (Carstensen, 1995). To study the dynamics of social relations, it is necessary to retain information about social relations over long periods, ideally over the life course. We intended to develop an instrument that would be meaningful across most of adult life, being aware of the limitations of an approach such as lower level of detail concerning, for example, the family category (the content of this category is to some degree decided/determined by the age of the respondent, that is, grandchildren, children, parents, grandparents). A measure applicable to several age groups provides the opportunity to study changes in social relations over time when applied to the same respondents several times across adult life although at the cost of level of detail. We tested the face validity of CSRQ by asking participants to fill in all items and immediately thereafter to give their comments on the instrument. Face validity could have been approached differently by, for example, a “think aloud technique.” However, as FDGs or individual interviews regarding the content of social relations in general took place immediately after the exposure to CSRQ, we did not want to dwell too long on each of the items in order not to guide these discussions unduly. Consequently, the face validity test in the present study is only a superficial test that aims to understand whether the instrument was comprehensible at a first glance and easy to fill in for the participants. The reliability of CSRQ was judged to be good in our 8-day test–retest analysis. The test–retest was carried out by the same researchers at all the three data collection sites minimizing the risk of bias by differences in instructions given. Furthermore, the study population was reasonably large with the inclusion of 94 participants, which lowers the risk of a few subjects skewing the results. The 8-day interval was chosen as the “ideal” distance, that is, long enough for not just mechanical repetition of an answer remembered and short enough for stability in structure and function of social relations to be expected. The study population had an overweight of women and was on average a little younger and belonged to lower educational groups than the CAMB cohort; optimally, at least more men should have been included. Furthermore, the sample included a mixture of people with and without ill-health and may not be representative of the middle-aged general population. This may have biased the results. However, we think that the reliability of the CSRQ is satisfactory. In conclusion, the CSRQ holds satisfactory face and content validity as well as reliability, and is suitable for measuring structure and function of


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social relations including the negative aspects among middle-aged individuals in a Scandinavian welfare society. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Danish Research Council (9801268) and the Nordea Denmark Foundation (02-2010-0385).

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