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PSYCHOGERIATRICS 2014; 14: 31–37
doi:10.1111/psyg.12036
ORIGINAL ARTICLE
The impact of giving support to others on older adults’ perceived health status Yadollah ABOLFATHI MOMTAZ,1 Rahimah IBRAHIM1,2 and Tengku A. HAMID1,2
1
Institute of Gerontology, and 2Department of Human Development and Family Studies, Faculty of Human Ecology, Universiti Putra Malaysia, Serdang, Malaysia Correspondence: Dr Rahimah Ibrahim PhD, Institute of Gerontology, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. Email: [email protected] Received 11 June 2013; revision received 17 September 2013; accepted 28 October 2013.
Key words: aged, giving social support, hierarchical regression, perceived health.
Abstract Background: Social support that may contribute to the physical and mental health of older adults is widely studied. However, much of the existing research has focused on the impact of receiving support; the effects of giving support have largely been neglected. Using the biopsychosocial perspective, this study aimed to examine the independent impact of giving support to others on older adults’ perceived health status. Methods: Data for this study were obtained from a nationwide community-based cross-sectional survey entitled ‘Determinants of Wellness among Older Malaysians: A Health Promotion Perspective’, which was conducted in 2010. To assess the unique effects of giving support on perceived health status, above and beyond other possible known factors, a four-step hierarchical regression model using SPSS was used to test the hypothesis. Results: The findings from the analysis revealed that giving support to others was a significant positive predictor of older adults’ perceived health status after receiving support, demographic variables and chronic medical conditions were considered. Further results showed that giving support to others had almost twice the effect on perceived health status (β = 0.11, P < 0.001) as receiving support (β = 0.06, P < 0.05). Conclusion: The findings from this study underscore the need to develop programmes that encourage older adults’ participation in productive activities such as caring for and helping others and volunteering.
INTRODUCTION Social support as an important factor in health and illness has been defined varyingly in the literature, but in general, it refers to the exchange of psychological and material resources between individuals to improve their ability to cope with stress.1 A growing body of research across a wide range of disciplines, including gerontology, sociology, psychology, and medicine, has revealed the protective and buffering effect of receiving social support on maintaining physical and mental health.2–5 Although the positive effects of receiving social support have been well documented,6,7 there is currently little evidence concerning the impact of giving support on the perceived health status of older © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
adults.8,9 Therefore, the main aim of this study is to examine the independent impact of giving social support on older adults’ perceived health status from a biopsychosocial point of view. Despite having different ethnic identities, older Malaysians grew up with the cultural and religious values of traditional communities that emphasize kinship, giving and sharing within and beyond the family. For instance, among the Malays, the spirit of giving can be seen in cultural practices such as gotong-royong, which involves relatives and neighbours coming together to help one another at major celebrations and religious festivals.10,11 The practice of giving is also espoused through Islamic prac31
Y. Abolfathi Momtaz et al.
tices such as sedekah (voluntary giving), zakat (giving a portion of one’s resources to the needy to cleanse oneself, purifying income and property), and waqf (endowment for charitable purposes).12 Similar philosophies of giving are found in the teachings of Buddhism and Confucianism. Buddhism’s path of enlightenment and Confucianism’s concept of jen (or ren), for example, emphasize harmony in human relations through virtues such as courtesy, generosity and kindness.12,13 Hindus also believe that service through seva, or giving one’s self for the good of others without expecting anything in return, can be performed through one’s mind, body and wealth.12 In terms of practice, it has been found that older persons are active contributors in their families and communities. As a case in point, Ismail et al. analyzed a sample of households with older persons from the Malaysian Household Expenditure Survey 2004–2005 and found that on average older persons contribute towards half of the total household income.14 Similarly, from a 1999 national survey of older persons, intergenerational transfers from parents to adult children were evident through provision of financial assistance, home cooked meals, goods and groceries as well as services such as housework and babysitting.15 Therefore, giving and sharing are embedded in Malaysia’s sociocultural traditions and communal models of living,11 and older persons are actively participating in mutually supportive networks in the family. Nonetheless, these communal values are in flux amid modernization and development and have been relinquished for more liberal values of a civil society, namely individual rights and freedom.11,16 Theoretical framework Although the exact biopsychosocial mechanisms underlying the positive impact of giving social support on perceived health status are unknown, a complex set of factors may mediate this association. We concisely discuss several theories to explain the link between giving social support and health status. Self-determination theory Self-determination theory focuses on the mechanisms through which relational processes contribute to personal well-being and positive outcomes for relationships.17 According to this theory, all human beings have three basic psychological needs: autonomy, competence, and relatedness. These needs facilitate 32
greater well-being and vitality. Autonomy means the experience of behaving in accordance with an individual’s own interests. Competence refers to the tendency towards mastery, which is facilitated by conditions that provide positive feedback. Finally, relatedness is a propensity towards connectedness or belongingness with others that is enhanced when people interact warmly and respectfully with each other.17 This theory states how well social contexts may provide these basic psychological needs.18 Providing support to others promotes a person’s initiative, volition and integrity, facilitates satisfaction of the basic psychological needs, and enhances a person’s satisfaction and psychological well-being.19,20 Within this theory, people with intrinsic goals, compared to those with extrinsic goals, experience greater wellbeing.21 In their study, Deci et al. investigated the impact of giving support on the giver’s well-being after controlling for receiving support. They found that giving autonomy support to a friend is significantly related to well-being over and above the impact of receiving support from others.20 Similarly, after controlling for the benefit attained from receiving support, La Guardia and Patrick found that giving support had its own unique effects on the person.17 The findings from a study involving a sample of 423 elderly couples for 5 years showed that giving emotional support to one’s spouse reduced the risk of mortality by 30%.22 Generativity According to Erikson and Erikson’s psychosocial theory, generative behaviours become more important as people get older.23 In old age, adults are better able to go beyond their own needs and become more interested in their community and society. Generativity involves interacting with others to care for them. Giving support has positive mental health benefits for older adults.24 When older adults share their knowledge and experiences with others (generativity), this results in stronger connections with others (generativity and ego integrity) and consequently increases the feelings of meaning in life (ego integrity).24 It was found that generative behaviours are the most important predictors of ego integrity. For instance, the findings from a study on the role of generativity, autonomy, intimacy, identity, and trust on ego integrity in a sample of 520 older adults aged 55–84 years revealed that generativity alone explained 78% of the variance in ego integrity.25 © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Giving support and health status
Biological theory Another plausible explanation is that providing support increases activity in the ventral striatum and septal area. Moreover, this increased activity is associated with lower activity in both the right and left amygdalae (part of the limbic system), consequently leading to improved self-perceived health.26 Inagaki and Eisenberger explored the potentially beneficial impact of giving support to a loved one on the caregiving behaviour. Their findings showed that giving support may be beneficial not only for the receiver but also for the giver.26 In another study, Piferi and Lawler examinedexamined the impact of giving support to others on ambulatory blood pressure.27 They found that giving support to others is associated to lower systolic and diastolic blood pressure and arterial pressure. The authors concluded that providing social support to others benefits cardiovascular health status. Identity theory Another theory that may explain the impact of providing support on the mental health of older adults is identity theory. Identity theory predicts that increased reliance on support from others can reduce older adults’ sense of competence, which may disturb their identities with feelings of dependency. Consequently, disturbances in identities may decrease mental health. Providing support to others, however, can bolster role identity and promote older adults’ well-being.9,28 Within identity theory, Thomas examined the impact of giving and receiving support on well-being of a sample of 689 older adults.9 Results revealed that giving support to others promotes older adults’ well-being. However, receiving support was less important to the well-being of older adults.
METHODS Data for this study were obtained from the nationwide community-based cross-sectional survey entitled ‘Determinants of Wellness among Older Malaysian: A Health Promotion Perspective’, which was conducted in 2010. Geographically, the survey covered all of Malaysia’s older population residing in non-institutional living quarters. The National Household Sampling Frame was used in the sampling process. It consists of enumeration blocks derived © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
from the Population and Housing Census, Malaysia 2000. A two-multistage random sampling method was used to obtain the sample. In the first stage of sampling, enumeration blocks were selected, and in the second stage, living quarters of each selected enumeration block were randomly chosen. Finally, from each selected household one respondent 60 years and older was interviewed. Inclusion criteria for respondents were: (i) elderly Malaysian aged 60 years and above; (ii) capable of completing questionnaire orally; (iii) living in the community; and (iv) ambulatory. Exclusion criteria for this study were those who were bed ridden, living in an institution and had cognitive problems. Written consent was obtained from respondents prior to administration of questionnaires. Data were collected through face-toface interviews conducted in the respondent’s home by trained enumerators. With a response rate of 77%, a sample of 2563 respondents was successfully interviewed.
Measures Perceived health Perceived health status was investigated using a single-item question, which has already been used and validated among older Malaysian:29 ‘In general, how do you rate your health status?’ The question had five optional answers: 1-poor; 2-fair; 3-good; 4-very good; and 5-excellent. Because several researchers argue that outcome categorical variables with a 5-point Likert scales can be considered continuous variables,30 perceived health status was treated as a continuous variable in this study.
Giving and receiving support Giving and receiving support were measured with 10 items from the Medical Outcomes Study Social Support Survey.31 Because this survey is used solely to measure perceived social support, we modified the questions where the respondents were asked whether they had provided any social support to others including friends, neighbours, and relatives in the past 12 months in order to measure giving support. Respondents indicated whether they provided or received support by answering ‘yes’ or ‘no’. Responses were coded as yes (1) or no (0) for each of the support provided or received statements. 33
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Receiving support from others 1 When you talk, there is someone listen to you. 2 There is someone to give you information to help you understand a situation. 3 There is someone to give you good advice about a crisis. 4 There is someone to share problems/worries/fears with. 5 There is someone to take you to the doctor. 6 There is someone to prepare your meals if you are unable to do it yourself. 7 There is someone who shows you love and makes you feel wanted. 8 There is someone who has close relationship with you. 9 There is someone to have a good time with and to have fun with. 10 There is someone to do things with to help you to get your mind off things. Giving support to others 1 When they talk, you listen to them. 2 You give information to help them understand a situation. 3 You give good advice about a crisis. 4 You talk to them about themselves or their problems. 5 You take them to the doctor. 6 You prepare meals for them if they are unable to do so. 7 You show them love and make them feel wanted. 8 You have a close relationship with them. 9 You can have a good time with and have fun with them. 10 You can do things to help them to get their mind off things.
Control variables Previous studies have found that health condition and socioeconomic status may affect giving behaviours.32,33 For instance, Verbrugge and Chan’s study on a sample of older Singaporeans reported that seniors with low self-rated health were less likely to give any kind of help.33 To control for the possibility that any effects of giving support are owing to factors that may underlie both giving and perceived health status, they measured a variety of sociodemographic and health factors, including age, gender, marital status, years of education, household income adequacy, and chronic medical conditions (CMC). Household income adequacy Household income adequacy was measured using a single self-reported question: ‘Overall, how do you feel about your current income?’ Answer options were 1-can afford to buy daily needs only; 2-can afford to buy most of what I want but not all; 3-can afford to have all I want; and 4-can afford to have all I want and have savings. CMC CMC were assessed using a self-report checklist of the 16 most common CMC encountered by older 34
adults. Respondents were asked whether they had had specific CMC including hypertension, joint pain (arthritis), heart disease, diabetes, visual problems, hypercholesterolaemia, hearing problems, gastritis, asthma, kidney disease, skin disorders, tuberculosis, cancer, effects of stroke, liver disease and psychiatric problems during the previous 12 months. Ethics and approvals The study was approved by the Ministry of Health, Malaysia and was in compliance with the Declaration of Helsinki and the World Medical Association guidelines. Analytic techniques A four-step hierarchical regression model using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA) was used to examine the effect of providing support on perceived health status, after receiving support, demographic and health factors were controlled. The first step of this analysis regressed perceived health on demographic factors. The second model was built on Model 1 by adding receiving support. In the third step, providing support was entered. The final model included CMC. It should be noted, although linear regression models are considered more appropriate for continuous dependent variables, they have also been recognized as robust models with dichotomous variables and are largely used with dichotomous outcome variables such as self-rated health.34–37
RESULTS Of the 2563 respondents who were interviewed, 11 cases were dropped from final analysis because of missing data or incomplete information. The mean age of the respondents in the sample was 69.09 1 6.88 years (range: 60–103 years). Fifty-five per cent of the respondents were women and 58% were married. Table 1 presents the means, standard deviations, and Cronbach’s α for the variables used in the study. Because the main aim of this study was to examine the effect of providing support to others on perceived health status after other possible variables had been considered, a four-step hierarchical regression analysis was performed. Table 2 provides a summary of the hierarchical regression analyses. Prior to the hierarchical regression analyses, collinearity diagnostics were examined for multicollinearity of the independent variables. The results of the collinearity diagnostic tests, © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Giving support and health status
including variance inflation factors less than 2.0 and tolerance values greater than 0.2 for all variables,38 indicated that the independent variables were not highly correlated. Thus, the problem of multicollinearity was ruled out. First step Previous research has found that respondents’ demographic characteristics likely influence older adults’ perceived health status. As such, demographic predictor variables including age, gender (male = 1; female = 0), marital status (married = 1; unmarried = 0), years of education, and household income adequacy were block entered in the first step. This block of demographic variables yielded a significant overall model, F (5, 2404) = 32.92, P < 0.001, explaining 11% of the variance in perceived health status. Second step This second step produced a significant overall model, F (6, 2403) = 33.33, P < 0.001, that explained an additional 1% of the variance in perceived health
Table 1 Descriptive statistics of the variables Variables
Mean 1 SD
Cronbach’s α
Age (years) Education (years) Household income adequacy CMC (n) Perceived health Receiving support Giving support
69.09 3.43 1.88 1.65 3.36 9.02 8.05
1 1 1 1 1 1 1
0.867 0.869
6.88 3.72 1.08 1.74 0.87 1.90 2.52
CMC, chronic medical conditions.
beyond the demographic variables. As Table 2 indicates, receiving support was significantly associated with perceived health after demographic variables were controlled (P < 0.001). Third step The addition of providing support produced a significant overall model, F (7, 2402) = 32.62, P < 0.001, that explained an additional 1% of variance to Model 2. The change in R2 indicates that the addition of providing support to known correlates of perceived health, such as demographic variables and receiving support, accounted for a significantly greater amount of variance in perceived health. As shown in Table 2, when both receiving and giving support were entered in the model, giving (β = 0.12, P < 0.001), rather than receiving (β = 0.05, P < 0.05), was the stronger predictor of perceived health status. Fourth step Because older adults with CMC may have difficulty providing support to others, CMC were added to the model in order to control for the alternative possibility that individuals who give support to others have better perceived health because they are more physically robust than those who do not give support. The findings from this step showed that after adding CMC to model, the impact of providing support on perceived health remained significant (β = 0.11, P < 0.001). This suggests that the relationship between providing support and perceived health may be specifically related to the consequences of providing support per se.
Table 2 Summary of hierarchical regression analyses Variable Age Gender Marital status Education Household income adequacy Receiving support Giving support CMC R2 Δ R2 ΔF
B −0.02 −0.01 0.04 0.03 0.09
Model 1 SE 0.01 0.04 0.04 0.01 0.02
β
B
−0.12** 0.01 0.02 0.11** 0.11**
−0.01 −0.03 0.01 0.02 0.08 0.05
0.064 0.064 32.92**
Model 2 SE 0.01 0.04 0.04 0.01 0.02 0.01
0.077 0.013 33.17**
β
B
−0.12** −0.01 0.01 0.10** 0.10** 0.12**
−0.01 −0.04 −0.01 0.02 0.08 0.02 0.04
Model 3 SE 0.01 0.04 0.04 0.01 0.02 0.01 0.01 0.087 0.010 26.25**
β
B
−0.10** −0.02 −0.01 0.09** 0.10** 0.05* 0.12**
−0.01 −0.04 −0.01 0.02 0.07 0.03 0.04 −0.16
Model 4 SE 0.01 0.04 0.04 0.01 0.02 0.01 0.01 0.01 0.189 0.102 301.07**
β −0.08** −0.02 −0.01 0.09** 0.09** 0.06* 0.11** −0.32**
*P < 0.05; **P < 0.001. CMC, chronic medical conditions.
© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
35
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DISCUSSION This study aimed to investigate the potential impact of giving support to others on the perceived health status of older adults beyond the effects of receiving support. Both sociodemographic and health status were controlled. In line with the existing, albeit scant research,9,39 the findings from the present study provided evidence that giving support to others can benefit older adults’ perceived health status over and above receiving support. There are several ways that giving social support may enhance perceived health status. First, from a biological perspective, giving social support results in increased activity in the ventral striatum and septal area, which leads to lower activity in both the right and left amygdalae and, thus, enhanced perceived health status.26 From a psychological point of view, giving support to others as a form of generative behaviours results in stronger connections with others and bolsters the self-esteem of providers. Consequently, this increases feelings of meaning in life and enhances perceived health status.24,39 Also, giving support may facilitate satisfaction of the basic psychological needs that lead to the enhanced psychological well-being of people.19,20 Finally, according to a sociological perspective, giving support can bolster role identity that may promote older adults’ well-being.9,28 In sum, the findings from this study revealed and supported the argument that giving support to others may contribute to higher levels of happiness and life satisfaction in old age. The primary limitation of the current study is related to measurement of perceived health status, which was conducted using a singleitem measure of self-perceived health. However, it is noteworthy to mention that this measurement method of overall health status has long been used in social and epidemiological studies and has received substantial validation.40,41 The second limitation is the cross-sectional nature of the study, which might limit its ability to make definitive conclusions about the impact of providing support on perceived health status. Therefore, a longitudinal research approach would be useful to capture the causal relationship between giving support and health status. Despite these limitations, the current study’s findings underscore the need to develop programmes that encourage older adults’ participation in productive activities such as caring for and helping other people and volunteering. The main contribution of the current 36
research is that this study is one of the few studies that have attempted to reveal the impact of giving support to others on the health status of older adults.
ACKNOWLEDGMENTS This study was supported by the Ministry of Health, Malaysia (Putrajaya, Malaysia) [Project Code: NMRR09-443-4148]. The authors are thankful to the participants in the study, editor, and anonymous reviewers.
REFERENCES 1 Ko LK, Lewis MA. The role of giving and receiving emotional support in depressive symptomatology among older couples: an application of the actor-partner interdependence model. J Soc Pers Relat 2011; 28: 83–99. 2 Momtaz YA, Hamid TA, Ibrahim R, Yahaya N, Abdullah SS. Moderating effect of Islamic religiosity on the relationship between chronic medical conditions and psychological wellbeing among elderly Malays. Psychogeriatrics 2012; 12: 43–53. 3 White AM, Philogene GS, Fine L, Sinha S. Social support and self-reported health status of older adults in the United States. Am J Public Health 2009; 99: 1872–1878. 4 Cohen S. Social relationships and health. Am Psychol 2004; 59: 676–684. 5 Momtaz YA, Hamid TA, Yusoff S et al. Loneliness as a risk factor for hypertension in later life. J Aging Health 2012; 24: 696–710. 6 Yahaya N, Momtaz YA, Hamid TA, Abdullah SS. Social support and psychological well-being among older Malay women in Peninsular Malaysia. Indian J Gerontol 2013; 27: 320–332. 7 Ibrahim R, Momtaz YA, Hamid TA. Social isolation in older Malaysians: prevalence and risk factors. Psychogeriatrics 2013; 13: 71–79. 8 Brown SL, Nesse RM, Vinokur AD, Smith DM. Providing social support may be more beneficial than receiving it: results from a prospective study of mortality. Psychol Sci 2003; 14: 320–327. 9 Thomas PA. Is it better to give or to receive? Social support and the well-being of older adults. J Gerontol B Psychol Sci Soc Sci 2009; 65: 351–357. 10 Thompson EC. Rural villages as socially urban spaces in Malaysia. Urban Stud 2004; 41: 2357–2376. 11 Josie MF, Ibrahim AR, eds. A Giving Society: The State of Philantropy in Malaysia. Penang: Universiti Sains Malaysia Press, 2002. 12 Cheah ASB. Some dimensions of religious giving. In: Josie MF, Ibrahim AR, eds. A Giving Society: The State of Philantropy in Malaysia. Penang: Universiti Sains Malaysia Press, 2002; 43–74. 13 Hill JS. Religion and the shaping of East Asian management styles: a conceptual examination. J Asia Pac Bus 2007; 8: 59–88. 14 Ismail NA, Masud J, Sulaiman H. Older Persons Contribution to Household Income in Malaysia. IAGG’s IXth Asia/Oceania Regional Congress. Melbourne, Australia: Vol Melbourne Convention Centre, 2010. 15 Hamid TA. Intergenerational relationships in Malaysia: what has changed and what has not. 2010 Paper presented at: Workshop on Changing Intergenerational Relationships as Europe and Asia Age 2010; The Oxford Institute of Ageing, University of Oxford, UK. 16 Verma V. Malaysia, State and Civil Society in Transition. London: Lynne Rienner, 2002.
© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Giving support and health status 17 La Guardia JG, Patrick H. Self-determination theory as a fundamental theory of close relationships. Can Psychol 2008; 49: 201–209. 18 Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000; 55: 68–78. 19 Deci EL, Ryan RM. Self-determination theory in health care and its relations to motivational interviewing: a few comments. Int J Behav Nutr Phys Act 2012; 9: 24. 20 Deci EL, La Guardia JG, Moller AC, Scheiner MJ, Ryan RM. On the benefits of giving as well as receiving autonomy support: mutuality in close friendships. Pers Soc Psychol Bull 2006; 32 313–327. 21 Mollica C. Interpersonal Dimensions of Goal Pursuit: Goal Support, Shared Goals, Communal Strength, and Generativity in Relationship to Self-Determination Theory [Ph.D]. Miami: University of Miami, 2008. 22 Brown SL. Health effects of caregiving: studies of helping behavior needed. Alzheimers Care Today 2007; 8: 235– 246. 23 Erikson EH, Erikson JM. The Life Cycle Completed. New York: WW Norton & Company, 1998. 24 Piercy KW, Cheek C, Teemant B. Challenges and psychosocial growth for older volunteers giving intensive humanitarian service. Gerontologist 2011; 51: 550–560. doi: 10.1093/geront/ gnr1013. 25 Hannah MT, Domino G, Figueredo AJ, Hendrickson R. The prediction of ego integrity in older persons. Educ Psychol Meas 1996; 56: 930–950. 26 Inagaki TK, Eisenberger NI. Neural correlates of giving support to a loved one. Psychosom Med 2012; 74: 3–7. 27 Piferi RL, Lawler KA. Social support and ambulatory blood pressure: an examination of both receiving and giving. Int J Psychophysiol 2006; 62: 328–336.
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28 Siebert DC, Mutran EJ, Reitzes DC. Friendship and social support: the importance of role identity to aging adults. Soc Work 1999; 44: 522–533. 29 Hamid TA, Momtaz YA, Rashid SNSA. Older women and lower self-rated health. Educ Gerontol 2010; 36: 521–528. 30 Garson GD. Guide to Writing Empirical Papers, Theses and Dissertations. New York: Marcel Dekker, 2001. 31 Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991; 32: 705–714. 32 Brown SL, Smith DM, Schulz R et al. Caregiving behavior is associated with decreased mortality risk. Psychol Sci 2009; 20: 488–494. 33 Verbrugge LM, Chan A. Giving help in return: family reciprocity by older Singaporeans. Ageing Soc 2008; 28: 5–34. 34 Hellevik O. Linear versus logistic regression when the dependent variable is a dichotomy. Qual Quant 2009; 43: 59–74. 35 Lee Y, Shinkai S. A comparison of correlates of self-rated health and functional disability of older persons in the Far East: Japan and Korea. Arch Gerontol Geriatr 2003; 37: 63–76. 36 Parkai T, Deeg DJH, Bosscher RJ, Launer LLJ. Physical activity and self-rated health among 55-to 89-year-old Dutch people. J Aging Health 1998; 10: 311–326. 37 Machacova K, Lysack C, Neufeld S. Self-rated health among persons with spinal cord injury: what is the role of physical ability? J Spinal Cord Med 2011; 34: 265–272. 38 Tabachnick BG, Fidell LS. Using Multivariate Statistics, 5th edn. Boston: Allyn and Bacon, 2007. 39 Krause N, Shaw BA. Giving social support to others, socioeconomic status, and changes in self-esteem in late life. J Gerontol B Psychol Sci Soc Sci 2000; 55: S323–S333. 40 Chandola T, Jenkinson C. Validating self-rated health in different ethnic groups. Ethn Health 2000; 5: 151–159. 41 Finch BK, Hummer RA, Reindl M, Vega WA. Validity of self-rated health among Latinos. Am J Epidemiol 2002; 155: 755–759.
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PSYCHOGERIATRICS 2014; 14: 31–37
doi:10.1111/psyg.12036
ORIGINAL ARTICLE
The impact of giving support to others on older adults’ perceived health status Yadollah ABOLFATHI MOMTAZ,1 Rahimah IBRAHIM1,2 and Tengku A. HAMID1,2
1
Institute of Gerontology, and 2Department of Human Development and Family Studies, Faculty of Human Ecology, Universiti Putra Malaysia, Serdang, Malaysia Correspondence: Dr Rahimah Ibrahim PhD, Institute of Gerontology, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. Email: [email protected] Received 11 June 2013; revision received 17 September 2013; accepted 28 October 2013.
Key words: aged, giving social support, hierarchical regression, perceived health.
Abstract Background: Social support that may contribute to the physical and mental health of older adults is widely studied. However, much of the existing research has focused on the impact of receiving support; the effects of giving support have largely been neglected. Using the biopsychosocial perspective, this study aimed to examine the independent impact of giving support to others on older adults’ perceived health status. Methods: Data for this study were obtained from a nationwide community-based cross-sectional survey entitled ‘Determinants of Wellness among Older Malaysians: A Health Promotion Perspective’, which was conducted in 2010. To assess the unique effects of giving support on perceived health status, above and beyond other possible known factors, a four-step hierarchical regression model using SPSS was used to test the hypothesis. Results: The findings from the analysis revealed that giving support to others was a significant positive predictor of older adults’ perceived health status after receiving support, demographic variables and chronic medical conditions were considered. Further results showed that giving support to others had almost twice the effect on perceived health status (β = 0.11, P < 0.001) as receiving support (β = 0.06, P < 0.05). Conclusion: The findings from this study underscore the need to develop programmes that encourage older adults’ participation in productive activities such as caring for and helping others and volunteering.
INTRODUCTION Social support as an important factor in health and illness has been defined varyingly in the literature, but in general, it refers to the exchange of psychological and material resources between individuals to improve their ability to cope with stress.1 A growing body of research across a wide range of disciplines, including gerontology, sociology, psychology, and medicine, has revealed the protective and buffering effect of receiving social support on maintaining physical and mental health.2–5 Although the positive effects of receiving social support have been well documented,6,7 there is currently little evidence concerning the impact of giving support on the perceived health status of older © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
adults.8,9 Therefore, the main aim of this study is to examine the independent impact of giving social support on older adults’ perceived health status from a biopsychosocial point of view. Despite having different ethnic identities, older Malaysians grew up with the cultural and religious values of traditional communities that emphasize kinship, giving and sharing within and beyond the family. For instance, among the Malays, the spirit of giving can be seen in cultural practices such as gotong-royong, which involves relatives and neighbours coming together to help one another at major celebrations and religious festivals.10,11 The practice of giving is also espoused through Islamic prac31
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tices such as sedekah (voluntary giving), zakat (giving a portion of one’s resources to the needy to cleanse oneself, purifying income and property), and waqf (endowment for charitable purposes).12 Similar philosophies of giving are found in the teachings of Buddhism and Confucianism. Buddhism’s path of enlightenment and Confucianism’s concept of jen (or ren), for example, emphasize harmony in human relations through virtues such as courtesy, generosity and kindness.12,13 Hindus also believe that service through seva, or giving one’s self for the good of others without expecting anything in return, can be performed through one’s mind, body and wealth.12 In terms of practice, it has been found that older persons are active contributors in their families and communities. As a case in point, Ismail et al. analyzed a sample of households with older persons from the Malaysian Household Expenditure Survey 2004–2005 and found that on average older persons contribute towards half of the total household income.14 Similarly, from a 1999 national survey of older persons, intergenerational transfers from parents to adult children were evident through provision of financial assistance, home cooked meals, goods and groceries as well as services such as housework and babysitting.15 Therefore, giving and sharing are embedded in Malaysia’s sociocultural traditions and communal models of living,11 and older persons are actively participating in mutually supportive networks in the family. Nonetheless, these communal values are in flux amid modernization and development and have been relinquished for more liberal values of a civil society, namely individual rights and freedom.11,16 Theoretical framework Although the exact biopsychosocial mechanisms underlying the positive impact of giving social support on perceived health status are unknown, a complex set of factors may mediate this association. We concisely discuss several theories to explain the link between giving social support and health status. Self-determination theory Self-determination theory focuses on the mechanisms through which relational processes contribute to personal well-being and positive outcomes for relationships.17 According to this theory, all human beings have three basic psychological needs: autonomy, competence, and relatedness. These needs facilitate 32
greater well-being and vitality. Autonomy means the experience of behaving in accordance with an individual’s own interests. Competence refers to the tendency towards mastery, which is facilitated by conditions that provide positive feedback. Finally, relatedness is a propensity towards connectedness or belongingness with others that is enhanced when people interact warmly and respectfully with each other.17 This theory states how well social contexts may provide these basic psychological needs.18 Providing support to others promotes a person’s initiative, volition and integrity, facilitates satisfaction of the basic psychological needs, and enhances a person’s satisfaction and psychological well-being.19,20 Within this theory, people with intrinsic goals, compared to those with extrinsic goals, experience greater wellbeing.21 In their study, Deci et al. investigated the impact of giving support on the giver’s well-being after controlling for receiving support. They found that giving autonomy support to a friend is significantly related to well-being over and above the impact of receiving support from others.20 Similarly, after controlling for the benefit attained from receiving support, La Guardia and Patrick found that giving support had its own unique effects on the person.17 The findings from a study involving a sample of 423 elderly couples for 5 years showed that giving emotional support to one’s spouse reduced the risk of mortality by 30%.22 Generativity According to Erikson and Erikson’s psychosocial theory, generative behaviours become more important as people get older.23 In old age, adults are better able to go beyond their own needs and become more interested in their community and society. Generativity involves interacting with others to care for them. Giving support has positive mental health benefits for older adults.24 When older adults share their knowledge and experiences with others (generativity), this results in stronger connections with others (generativity and ego integrity) and consequently increases the feelings of meaning in life (ego integrity).24 It was found that generative behaviours are the most important predictors of ego integrity. For instance, the findings from a study on the role of generativity, autonomy, intimacy, identity, and trust on ego integrity in a sample of 520 older adults aged 55–84 years revealed that generativity alone explained 78% of the variance in ego integrity.25 © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
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Biological theory Another plausible explanation is that providing support increases activity in the ventral striatum and septal area. Moreover, this increased activity is associated with lower activity in both the right and left amygdalae (part of the limbic system), consequently leading to improved self-perceived health.26 Inagaki and Eisenberger explored the potentially beneficial impact of giving support to a loved one on the caregiving behaviour. Their findings showed that giving support may be beneficial not only for the receiver but also for the giver.26 In another study, Piferi and Lawler examinedexamined the impact of giving support to others on ambulatory blood pressure.27 They found that giving support to others is associated to lower systolic and diastolic blood pressure and arterial pressure. The authors concluded that providing social support to others benefits cardiovascular health status. Identity theory Another theory that may explain the impact of providing support on the mental health of older adults is identity theory. Identity theory predicts that increased reliance on support from others can reduce older adults’ sense of competence, which may disturb their identities with feelings of dependency. Consequently, disturbances in identities may decrease mental health. Providing support to others, however, can bolster role identity and promote older adults’ well-being.9,28 Within identity theory, Thomas examined the impact of giving and receiving support on well-being of a sample of 689 older adults.9 Results revealed that giving support to others promotes older adults’ well-being. However, receiving support was less important to the well-being of older adults.
METHODS Data for this study were obtained from the nationwide community-based cross-sectional survey entitled ‘Determinants of Wellness among Older Malaysian: A Health Promotion Perspective’, which was conducted in 2010. Geographically, the survey covered all of Malaysia’s older population residing in non-institutional living quarters. The National Household Sampling Frame was used in the sampling process. It consists of enumeration blocks derived © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
from the Population and Housing Census, Malaysia 2000. A two-multistage random sampling method was used to obtain the sample. In the first stage of sampling, enumeration blocks were selected, and in the second stage, living quarters of each selected enumeration block were randomly chosen. Finally, from each selected household one respondent 60 years and older was interviewed. Inclusion criteria for respondents were: (i) elderly Malaysian aged 60 years and above; (ii) capable of completing questionnaire orally; (iii) living in the community; and (iv) ambulatory. Exclusion criteria for this study were those who were bed ridden, living in an institution and had cognitive problems. Written consent was obtained from respondents prior to administration of questionnaires. Data were collected through face-toface interviews conducted in the respondent’s home by trained enumerators. With a response rate of 77%, a sample of 2563 respondents was successfully interviewed.
Measures Perceived health Perceived health status was investigated using a single-item question, which has already been used and validated among older Malaysian:29 ‘In general, how do you rate your health status?’ The question had five optional answers: 1-poor; 2-fair; 3-good; 4-very good; and 5-excellent. Because several researchers argue that outcome categorical variables with a 5-point Likert scales can be considered continuous variables,30 perceived health status was treated as a continuous variable in this study.
Giving and receiving support Giving and receiving support were measured with 10 items from the Medical Outcomes Study Social Support Survey.31 Because this survey is used solely to measure perceived social support, we modified the questions where the respondents were asked whether they had provided any social support to others including friends, neighbours, and relatives in the past 12 months in order to measure giving support. Respondents indicated whether they provided or received support by answering ‘yes’ or ‘no’. Responses were coded as yes (1) or no (0) for each of the support provided or received statements. 33
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Receiving support from others 1 When you talk, there is someone listen to you. 2 There is someone to give you information to help you understand a situation. 3 There is someone to give you good advice about a crisis. 4 There is someone to share problems/worries/fears with. 5 There is someone to take you to the doctor. 6 There is someone to prepare your meals if you are unable to do it yourself. 7 There is someone who shows you love and makes you feel wanted. 8 There is someone who has close relationship with you. 9 There is someone to have a good time with and to have fun with. 10 There is someone to do things with to help you to get your mind off things. Giving support to others 1 When they talk, you listen to them. 2 You give information to help them understand a situation. 3 You give good advice about a crisis. 4 You talk to them about themselves or their problems. 5 You take them to the doctor. 6 You prepare meals for them if they are unable to do so. 7 You show them love and make them feel wanted. 8 You have a close relationship with them. 9 You can have a good time with and have fun with them. 10 You can do things to help them to get their mind off things.
Control variables Previous studies have found that health condition and socioeconomic status may affect giving behaviours.32,33 For instance, Verbrugge and Chan’s study on a sample of older Singaporeans reported that seniors with low self-rated health were less likely to give any kind of help.33 To control for the possibility that any effects of giving support are owing to factors that may underlie both giving and perceived health status, they measured a variety of sociodemographic and health factors, including age, gender, marital status, years of education, household income adequacy, and chronic medical conditions (CMC). Household income adequacy Household income adequacy was measured using a single self-reported question: ‘Overall, how do you feel about your current income?’ Answer options were 1-can afford to buy daily needs only; 2-can afford to buy most of what I want but not all; 3-can afford to have all I want; and 4-can afford to have all I want and have savings. CMC CMC were assessed using a self-report checklist of the 16 most common CMC encountered by older 34
adults. Respondents were asked whether they had had specific CMC including hypertension, joint pain (arthritis), heart disease, diabetes, visual problems, hypercholesterolaemia, hearing problems, gastritis, asthma, kidney disease, skin disorders, tuberculosis, cancer, effects of stroke, liver disease and psychiatric problems during the previous 12 months. Ethics and approvals The study was approved by the Ministry of Health, Malaysia and was in compliance with the Declaration of Helsinki and the World Medical Association guidelines. Analytic techniques A four-step hierarchical regression model using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA) was used to examine the effect of providing support on perceived health status, after receiving support, demographic and health factors were controlled. The first step of this analysis regressed perceived health on demographic factors. The second model was built on Model 1 by adding receiving support. In the third step, providing support was entered. The final model included CMC. It should be noted, although linear regression models are considered more appropriate for continuous dependent variables, they have also been recognized as robust models with dichotomous variables and are largely used with dichotomous outcome variables such as self-rated health.34–37
RESULTS Of the 2563 respondents who were interviewed, 11 cases were dropped from final analysis because of missing data or incomplete information. The mean age of the respondents in the sample was 69.09 1 6.88 years (range: 60–103 years). Fifty-five per cent of the respondents were women and 58% were married. Table 1 presents the means, standard deviations, and Cronbach’s α for the variables used in the study. Because the main aim of this study was to examine the effect of providing support to others on perceived health status after other possible variables had been considered, a four-step hierarchical regression analysis was performed. Table 2 provides a summary of the hierarchical regression analyses. Prior to the hierarchical regression analyses, collinearity diagnostics were examined for multicollinearity of the independent variables. The results of the collinearity diagnostic tests, © 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
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including variance inflation factors less than 2.0 and tolerance values greater than 0.2 for all variables,38 indicated that the independent variables were not highly correlated. Thus, the problem of multicollinearity was ruled out. First step Previous research has found that respondents’ demographic characteristics likely influence older adults’ perceived health status. As such, demographic predictor variables including age, gender (male = 1; female = 0), marital status (married = 1; unmarried = 0), years of education, and household income adequacy were block entered in the first step. This block of demographic variables yielded a significant overall model, F (5, 2404) = 32.92, P < 0.001, explaining 11% of the variance in perceived health status. Second step This second step produced a significant overall model, F (6, 2403) = 33.33, P < 0.001, that explained an additional 1% of the variance in perceived health
Table 1 Descriptive statistics of the variables Variables
Mean 1 SD
Cronbach’s α
Age (years) Education (years) Household income adequacy CMC (n) Perceived health Receiving support Giving support
69.09 3.43 1.88 1.65 3.36 9.02 8.05
1 1 1 1 1 1 1
0.867 0.869
6.88 3.72 1.08 1.74 0.87 1.90 2.52
CMC, chronic medical conditions.
beyond the demographic variables. As Table 2 indicates, receiving support was significantly associated with perceived health after demographic variables were controlled (P < 0.001). Third step The addition of providing support produced a significant overall model, F (7, 2402) = 32.62, P < 0.001, that explained an additional 1% of variance to Model 2. The change in R2 indicates that the addition of providing support to known correlates of perceived health, such as demographic variables and receiving support, accounted for a significantly greater amount of variance in perceived health. As shown in Table 2, when both receiving and giving support were entered in the model, giving (β = 0.12, P < 0.001), rather than receiving (β = 0.05, P < 0.05), was the stronger predictor of perceived health status. Fourth step Because older adults with CMC may have difficulty providing support to others, CMC were added to the model in order to control for the alternative possibility that individuals who give support to others have better perceived health because they are more physically robust than those who do not give support. The findings from this step showed that after adding CMC to model, the impact of providing support on perceived health remained significant (β = 0.11, P < 0.001). This suggests that the relationship between providing support and perceived health may be specifically related to the consequences of providing support per se.
Table 2 Summary of hierarchical regression analyses Variable Age Gender Marital status Education Household income adequacy Receiving support Giving support CMC R2 Δ R2 ΔF
B −0.02 −0.01 0.04 0.03 0.09
Model 1 SE 0.01 0.04 0.04 0.01 0.02
β
B
−0.12** 0.01 0.02 0.11** 0.11**
−0.01 −0.03 0.01 0.02 0.08 0.05
0.064 0.064 32.92**
Model 2 SE 0.01 0.04 0.04 0.01 0.02 0.01
0.077 0.013 33.17**
β
B
−0.12** −0.01 0.01 0.10** 0.10** 0.12**
−0.01 −0.04 −0.01 0.02 0.08 0.02 0.04
Model 3 SE 0.01 0.04 0.04 0.01 0.02 0.01 0.01 0.087 0.010 26.25**
β
B
−0.10** −0.02 −0.01 0.09** 0.10** 0.05* 0.12**
−0.01 −0.04 −0.01 0.02 0.07 0.03 0.04 −0.16
Model 4 SE 0.01 0.04 0.04 0.01 0.02 0.01 0.01 0.01 0.189 0.102 301.07**
β −0.08** −0.02 −0.01 0.09** 0.09** 0.06* 0.11** −0.32**
*P < 0.05; **P < 0.001. CMC, chronic medical conditions.
© 2013 The Authors Psychogeriatrics © 2013 Japanese Psychogeriatric Society
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DISCUSSION This study aimed to investigate the potential impact of giving support to others on the perceived health status of older adults beyond the effects of receiving support. Both sociodemographic and health status were controlled. In line with the existing, albeit scant research,9,39 the findings from the present study provided evidence that giving support to others can benefit older adults’ perceived health status over and above receiving support. There are several ways that giving social support may enhance perceived health status. First, from a biological perspective, giving social support results in increased activity in the ventral striatum and septal area, which leads to lower activity in both the right and left amygdalae and, thus, enhanced perceived health status.26 From a psychological point of view, giving support to others as a form of generative behaviours results in stronger connections with others and bolsters the self-esteem of providers. Consequently, this increases feelings of meaning in life and enhances perceived health status.24,39 Also, giving support may facilitate satisfaction of the basic psychological needs that lead to the enhanced psychological well-being of people.19,20 Finally, according to a sociological perspective, giving support can bolster role identity that may promote older adults’ well-being.9,28 In sum, the findings from this study revealed and supported the argument that giving support to others may contribute to higher levels of happiness and life satisfaction in old age. The primary limitation of the current study is related to measurement of perceived health status, which was conducted using a singleitem measure of self-perceived health. However, it is noteworthy to mention that this measurement method of overall health status has long been used in social and epidemiological studies and has received substantial validation.40,41 The second limitation is the cross-sectional nature of the study, which might limit its ability to make definitive conclusions about the impact of providing support on perceived health status. Therefore, a longitudinal research approach would be useful to capture the causal relationship between giving support and health status. Despite these limitations, the current study’s findings underscore the need to develop programmes that encourage older adults’ participation in productive activities such as caring for and helping other people and volunteering. The main contribution of the current 36
research is that this study is one of the few studies that have attempted to reveal the impact of giving support to others on the health status of older adults.
ACKNOWLEDGMENTS This study was supported by the Ministry of Health, Malaysia (Putrajaya, Malaysia) [Project Code: NMRR09-443-4148]. The authors are thankful to the participants in the study, editor, and anonymous reviewers.
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