Lastly, disability was ascertained by asking individuals if they were able to carry out 8 activities of daily living ADLs [ 32 ] and 8 instrumental activities of daily living IADLs [ 33 ] alone, with help or not at all. For descriptive purposes, results were weighted by the sampling design coefficients. Differences between men and women were tested using chi square, Student-Fisher's t and Mann-Whitney U tests, depending on the indicator selected.
Bivariate analyses used a chi-square test for categorical variables, to test for differences in the percentages of those deceased in each category. For the continuous variables, means or medians for those alive and dead were calculated and the differences tested with a Student-Fisher's t or Mann-Whitney U test. Multivariate analyses were conducted following a proportional hazards model with non-weighted data. Two models were calculated, one for women and one for men. First, sociodemographic and social network variables were introduced; second, psychosocial mechanisms were incorporated; third, lifestyle, disease and disability variables were included as potential confounders.
Lastly, a model combining data on men and women was fitted which included only those variables that showed associations in the same direction in both sex-specific models. The statistical significance of interactions of social variables with sex was tested in the combined model. The proportionality of the model was checked by inspecting the distribution of Schoenfeld residuals against survival time and adding a time-dependent variable to the model [ 34 , 35 ].
The log-linear relationship between the hazard rate and the quantitative independent variables was ascertained by categorizing the quantitative variables in similar range groups to check if the coefficients for these categories followed a linear pattern [ 35 ].
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Analysis of residuals also enabled us to check this assumption and to detect the existence of influential values in the final model dfbetas. The presence of co-linearity was examined in accordance with standard criteria [ 36 ]. In order to minimise the number of individuals lost in multivariate analyses, a modified hot-deck approach was used for imputation. This strategy assigns each individual with a missing value in one variable receptor a randomly selected value of the same variable pertaining to a group of subjects donors who share certain characteristics with the receptor [ 37 , 38 ].
Of the 1, eligible subjects in the sample, 1, Their age, sex, marital status, education and self-perceived health distributions were similar to those of the Spanish National Health Survey.
In cases, information was provided by a proxy due to the subject's cognitive impairment It was possible to register more than one condition for each case. Three individuals did not provide any information on social relationships, and in two cases vital status was not known. This left a final study sample of 1, individuals.
This rate was lower than that of the eligible subjects not included in the analysis Non-response at baseline was higher among women and the very old. A description of the sample is provided in Table 2. Subjects tended to be married, with little education, and to have health and disability problems mean co-morbidity was higher than 3, only one-third rated their health as good or very good, and less than half were totally independent.
Social relationships were widespread: only Gender differences were observed with respect to most variables: women were older, less educated, in worse health, with more depressive symptoms and more disability.
Women exercised less than men, they lived alone more often, were more frequently widowed, and their family ties index was lower. In addition, their social participation activities were less diversified. Women contacted friends less frequently, and their appraisal of their role in the lives of their significant others was lower as compared to men. Having a confidant was as frequent among men as among women. Bivariate analyses showed a significant association between a higher level of social relationships and survival data not shown.http://donnsboatshop.com/includes/major/pixev-the-purchasing-and.php
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Only two variables, receipt of emotional support in both sexes and contacts with friends were not statistically associated with survival. Potential confounders were related to mortality in the expected direction except for co-morbidity in women. Tables 3 and 4 shows the models for the association between social relationships and survival separately for women and men, respectively, while Table 5 shows the same analysis for both sexes combined.
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No interaction of social network variables by sex was significant. Since marital status is a component of the family ties index and living arrangements are highly correlated with marital status, we have excluded both variables from the analysis. Receipt of emotional support was not included in the combined model because it showed non-significant, opposite associations for each sex, rendering the calculation of an across-sexes effect meaningless. The family ties index was dichotomised because there were too few individuals with one or no family ties to allow for estimation of coefficients in these categories.
These individuals were merged with those having an average of two monthly contacts. Redefined in this fashion, this variable was very significant for men, and its effect was partially explained by health and disability variables. Contacts with friends had no effect on survival. Diversified social participation had a protective effect, and showed a similar gradient for men and women.
However, the association lost significance when all health and disability variables were included in the model. Figure 1 displays the probability of being alive at each follow-up year for each more activity the individuals took part in, after adjustment for sociodemographic and other social relationships variables when health and disability variables were included, the gradient was partially lost, with the hazard ratio for those performing one activity closely approaching that of persons who performed no activities. After adjusting for socio-demographic, other social relationships and health and disability variables, the risk of death of an individual who did not participate in any of the activities was 1.
Estimated survival probabilities of individuals according to the number of social activities they take part in social participation index , after adjusting for sociodemographic and social relationships variables. Having a confidant showed a greater protective effect in men, but sex differences disappeared when health and disability variables were included. Receipt of emotional support was not associated with mortality. An increasing role of the individual in the lives of significant others showed a protective effect in both sexes, which reached statistical significance only in the combined model.
The significance was lost after adjusting for health and disability. Again, no evidence against a gradient of the variable effect was found. Four components of social relationships are associated with 6-year survival in this elderly Southern European population: contacts with family ties, participation in social activities, having a confidant, and playing a meaningful role in the lives of significant others. Contacts with family ties and having a confidant remain significantly associated with improved survival, whereas participation in social activities and meaningful role in the lives of significant others lose significance after adjustment for health and disability variables.
This suggests that the effects of social relationships on survival may be partly mediated by the fostering of better health and function. This population enjoys relatively high levels of social contact, centred on family life, as would be expected in a Mediterranean community. Nevertheless, these levels are not as high for women as for men.
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A National Survey has confirmed this finding, reporting fewer contacts with friends and relatives among Spanish women [ 39 ]. Women in our cohort show worse family ties indexes mainly because they are older and, consequently, more frequently widowed. In addition, they have fewer contacts with friends and less participation in social life.
This last result is congruent with findings in Finland [ 8 ] and Taiwan [ 19 ], but dissimilar to those in France [ 6 ] and Denmark [ 15 ] where there are no differences between sexes and the USA [ 11 ] where women enjoy a larger social network and more social participation.
Psychological and social outcomes of sport participation for older adults: a systematic review
Our tentative explanation for these differences is that women in our cohort have lived most of their lives in a cultural background that favoured their engagement in family life over their participation in activities outside home. We can hypothesize also that the still predominant patriarchal way of thinking in the Mediterranean culture has driven downward these women's self-perception of their capacity of helping and influencing others' lives. Our analyses show similar protective associations between social relationships and mortality for both sexes apart from that of the family ties index , so the more limited social relationships women enjoy make them less able to benefit from them.
Nevertheless, it is worth mentioning that one of the variables most strongly associated with survival — having a confidant — is equally distributed among men and women. Differences by sex in the association between community participation and survival in the elderly were not observed in another European community [ 8 ], but they were present in a Taiwanese one [ 19 ]. A USA study that included elderly and young individuals and used a general index of social integration described differential effects between the sexes [ 3 ].
It is hard to say whether or not these conflicting results can be attributed to the use of differential scales or to real geographical-cultural effects. Men with the highest diversity of family ties enjoy better survival. Out of the men with fewer than three family ties, were widowers, while only 36 had no children and 30 had no close relatives.
Moreover, when this variable was replaced in the model by marital status data not shown , the protective effect of being married was very similar to that of the dichotomised family ties index. Therefore, what our dichotomised index is measuring is probably the beneficial effect of being married for men, a finding well reported in the literature on the elderly [ 6 , 7 ].
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Community activities social participation have generally been reported as predictors of survival [ 2 , 8 — 10 , 18 ], although there is conflicting evidence from Sweden [ 40 ]. This is not due to higher physical and functional levels of those who participate in them, because, in our study and others, adjustment for health and function does not change the magnitude of the association of community participation with mortality.
Moreover, the same effects have been reported in elderly people with different levels of physical activity [ 41 ]. In the seminal Tecumseh study [ 42 ], leisure activities that did not include social contact reading, watching TV did not confer the protective effect generated by social activities, which rules out attributing the beneficial associations observed to entertainment alone. Qualitative research in Spain [ 43 ] sheds some light on the positive effects of community activities on mortality: For elderly people, participation in these activities is a way to maintain full participation in society and show that being old does not equal being useless, passive and dependent.
In addition, social activities provide room for personal contacts and a daily routine that is a substitute for productive and reproductive work. Having a confidant appears to be a very strong predictor of survival. It is somewhat surprising that this feature has not been thoroughly investigated in previous studies dealing with mortality. We are aware of only two pieces of research [ 22 , 44 ] which included this variable: no effect was observed in the last one, although its small sample size may have limited power.
On the contrary, the Australian cohort study found significant protective effects for having a confidant.
The mechanisms through which having this kind of support influence survival are included in the formulation of the question we used to explore this topic. Our item defined a confidant as someone whom the subject can talk to, confide in and trust. Therefore, it behaves as a summary measure of various health-related psychosocial mechanisms.
Apart from this increase in overall survival, confidant availability has been reported to reduce the risk of cardiac events after infarction [ 45 ], cardiovascular death in patients with ischemic disease [ 46 ] and depressive symptomatology incidence among the elderly [ 47 ]. The Australian study [ 22 ] and others [ 14 , 19 ] have found that having and contacting friends postpones death.
Our results show this not to be the case in a Mediterranean community where, probably, family ties are more highly regarded. Of the other two psychosocial mechanisms considered, receipt of social support and playing an important role in the lives of significant others, only the latter is protective. A study in Japan found that a sense of "present usefulness to others and society" in elderly participants was predictive of longer survival even after adjusting for self-rated health [ 21 ].
However, the sense of usefulness was evaluated with a single question, whereas we used a scale, a procedure more suitable for measuring elaborated constructs. Conceptually related variables, such as the ability to take care of others among functionally impaired elderly persons [ 15 ] or the emotional and instrumental support given to the spouse among the community dwelling elderly [ 20 ] have shown some beneficial effects. They found that higher levels were associated protectively with better lower-body function as well as less ADL difficulty, hospitalisation and mortality, even after adjusting for socio-demographic, medical conditions and baseline disability variables.
In a recent study, feelings of worth and emotional support were also associated with survival in very elderly women [ 49 ]. This paper provides limited information on the pathways through which social networks generate their effects. The question remains as to the extent to which our results can be applied to other populations. Nevertheless, cultural differences among the Spanish regions exist, although in all of them, as in other Southern European communities, family plays a central role in the social networks of the older population.
Our results are based on a Mediterranean community. Since social relationship patterns are culturally dependent, it would be necessary to test our findings on the effects of roles and confidants in other populations. Therefore, the information collected on this topic is very detailed. This applies especially to psychosocial mechanisms — an area which has been studied less often. These complex constructs require batteries of questions to allow collection of valid information [ 50 ]. For this study, a new scale was developed based on previous research to separate two types of social support in relation to each tie: receipt of emotional support and an evaluation of the role the individual plays in the lives of significant others.