|Table of Contents|
Table of Contents
Chapter 1. Introduction
Chapter 2. Network analysis
Chapter 3. Network variables and ACLF relocation
Chapter 4. Literature review: Network variables and institutionalization
Chapter 5. Data and methods
Chapter 6. The participants: The new residents
Chapter 7. Between-group network differences
Chapter 8. The process of institutionalization
Chapter 9. Network variables as predictors of ACLF entry
Chapter 10. The participants: The residents six months later
Chapter 11. Network variables as predictors of tie duration and returning home
Chapter 12. Conclusions: Theoretical and practical implications
Appendix A. Emotional bondedness scale
Appendix B. Short portable mental status questionnaire
Appendix C. Index of independence in activities of daily living
Appendix D. Initial questionnaire addressed to resident
Appendix E. Initial questionnaire addressed to resident’s closest other
Appendix F. Follow-up questionnaire addressed to resident
Appendix G. Follow-up questionnaire addressed to resident’s closest other
Appendix H. Means and standard deviations of the characteristics of new resident’s networks
Appendix I. Between-group network differences
Appendix J. Variable effects on the process of ACLF entry
Appendix K. Variable effects on returning home and tie duration
PRIMARY SOCIAL NETWORK:
PREDICTORS AND CONSEQUENCES OF
ENTERING AN ADULT CONGREGATE LIVING FACILITY
MARY J. BEAR
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA 1986
Mary J. Bear
There are many individuals who have given information, encouragement, and guidance toward the completion of this dissertation. Primary among them are the author's family and friends, her chairman and the members of her doctoral committee, the residents and their closest others who participated in this study, and the managers of the ACLFs who invited her into their facilities. To all of these people, sincere thanks are extended. Additionally, the author wishes especially to acknowledge her grandparents, who instilled in her a sense of love and respect for elderly people.
TABLE OF CONTENTS
ACKNOWLEDGMENTS . . . . . . . . . .
ABSTRACT . . . . . . . . . . . viii
ONE INTRODUCTION . . . . . . . . 1
Caring for the Elderly . . . . 1
The Adult Congregate Living
Facility . . . . . . . 5
Theoretical Gaps . . . . . . 7
The Focal Problem . . . . . 5
TWO NETWORK ANALYSIS . . . . . . . 12
Emergence and Development . . . 12 Morphological Concepts . . . . 16 Interactional Concepts . . . . 18
THREE NETWORK VARIABLES AND ACLF RELOCATION . . . . . . . . 27
Labeling and Referral . . . . 27 Illness and Illness Behavior . . . 33 Tie Duration 0 0 0 . . 0 0 0 0 35 Relocation to Home o o . . o 37
FOUR LITERATURE REVIEW:
NETWORK VARIABLES AND
INSTITUTIONALIZATION o o o . . o o 40
FIVE DATA AND METHODS o o o o . o o o o 68
Sampling and Data Collection o o 68 Network Delimitation 0 75
Measurement of Dependent a;i;bieL 0 78
Measurement of Independent
Variables o o . . . o . 87
six THE PARTICIPANTS: THE NEW
RESIDENTS . . . . . . . . 97
Presenting Demographic and
Health Profi .... .. .. 97
Characteristics . . . . . 100 Range . . . . . . . 101
Density and Degree . . . 103 Interactional Network
Characteristics . . . . . 105 Tie Content and Directedness . 105 Frequency and Duration . . i11
SEVEN BETWEEN-GROUP NETWORK DIFFERENCES *. 115
Differences by Sex * . 117
Differences by Race . . . .. 120
Socioeconomic Differences . . . 123 Health-Related Differences . . . 127
EIGHT THE PROCESS OF INSTITUTIONALIZATION . . 132
Labeling and Referral . . . . 132 The Situation before the Move . . 137 Ego's Feelings about the Move ... 143
NINE NETWORK VARIABLES AS PREDICTORS OF
ACLF ENTRY . . . . . . . . 146
Labeling . . . . . . . 148
Ego's Presenting Health*Status . . 157 Network Deficient Residents . . 164 Deficient Total and Relative Networks *. . ... 165
Deficient Nonrelative Network .. .. .. .. .. 167
TEN THE PARTICIPANTS: THE RESIDENTS SIX
MONTHS LATER .9999.99.999999999 174
Place of Residence . . . . . 174 Perceived Fit . .. ... .. .. 177
Ego's Health . . . . . . 179
Alter's Response .* . . . 181
Characteristics . .* . . . 183
Contact Frequency . . . . 183 Tie Content and Directedness. 188
ELEVEN NETWORK VARIABLES AS PREDICTORS OF
TIE DURATION AND RETURNING HOME . . . 193
Returning Home . . . . . 194
Tie Duration . . . . . . 202
Contact Frequency . . 0 0 0 0 204 Closest Other Contact Frequency . . . . . 216
Material Links . . . . 225
TWELVE CONCLUSIONS: THEORETICAL AND
PRACTICAL IMPLICATIONS . . . . . 233
Theoretical Implications and
Directions for Future Research 234
Entering the ACLF . . . . 234 Tie Duration and Returning Home . . . . . . 241
Practical Implications . . . . 244 Strategies to Improve Utilization . . . . . 245 Strategies to Improve ACLF Caring . . . . . 249
A EMOTIONAL BONDEDNESS SCALE . . . . 255
B SHORT PORTABLE MENTAL STATUS
QUESTIONNAIRE . . . . . . . 257
C INDEX OF INDEPENDENCE IN ACTIVITIES
OF DAILY LIVING . . . . . . . 259
D INITIAL QUESTIONNAIRE ADDRESSED
TO RESIDENT . . . . . . . . 263
E INITIAL QUESTIONNAIRE ADDRESSED TO
RESIDENT'S CLOSEST OTHER . . . . 271
F FOLLOW-UP QUESTIONNAIRE ADDRESSED
TO RESIDENT . . . . . . . . 279
G FOLLOW-UP QUESTIONNAIRE ADDRESSED
TO RESIDENT'S CLOSEST OTHER . . . . 287
H MEANS AND STANDARD DEVIATIONS
OF THE CHARACTERISTICS OF NEW
RESIDENT'S NETWORKS . . . . . . 296
I BETWEEN-GROUP NETWORK DIFFERENCES 300
i VARIABLE EFFECTS ON THE PROCESS
OF ACLF ENTRY . . . . . . . 314
K VARIABLE EFFECTS ON RETURNING HOME
AND TIE DURATION . . . . . . 322
REFERENCES . . . . . . . . . 335
BIOGRAPHICAL SKETCH . . . . . . 347
Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
PRIMARY SOCIAL NETWORK:
PREDICTORS AND CONSEQUENCES OF
ENTERING AN ADULT CONGREGATE LIVING FACILITY By
Mary J. Bear
Chairman: Gordon F. Streib Major Department: Sociology
This is a longitudinal study of the effects of the
elderly's networks on (a) the process of ACLF (Adult Congregate Living Facility) entry, (b) the duration of these network ties after ACLF entry and (c) the likelihood of returning home after ACLF entry. Data were collected from 81 ACLF residents aged 60 and older and their closest other via personal interviews within two months of the residents' ACLF entry and then six months later. Sampling was limited to ACLFs licensed for up to 50 residents in Orange or Seminole County, Florida. Interviews included open- and close-ended questions and incorporated standardized measurement tools. A combination of multiple and logistic regression and analysis of descriptive data was done.
Both network variables and the control, socioeconomic status, were demonstrated to affect ACLF entry. The viii
intensity of the elderly's personal relationships and the source paying for their ACLF care explained the differential involvement of the elderly's formal and informal networks in ACLF entry. Intensity was directly related to the probability of professionals labeling the elderly "out of place" in their homes. Having one's care state-financed was directly related to both the probability of being professionally labeled and professionally referred to an ACLF. The severity of the elderly's health at ACLF entry was directly related to the density and degree of their networks and the intensity of their relationships with their closest others.
The density of the elderly's networks had the strongest effect on the duration of their ties after ACLF entry. The higher the density of the elderly's networks at ACLF entry, the more likely their ties endured. Secondary direct effects were also shown for reciprocity, better health being state-financed, white, and having returned home. The intensity of the elderly's ties did not explain tie duration.
The "problem of return" was not inherent in ACLF entry.
Being in better health had the greatest effect on returning home. However, nonwhites, private payers, and those with lower network bondedness were also more likely to return home.
Caring for the Elderly
Modernization has yielded many positive consequences in the United Statest as can be witnessed in the advances demonstrated in health technology, economic technology, literacy and mass education and urbanization. Yet as outlined by Cowgill (1974), each of these outcomes has led to a multifaceted scenario of secondary consequences. Primary among them, in terms of this dissertation, are (a) the aging of our population, (b) the increasing absolute and relative cost of health care in our society, and (c) the restructuring of the American family.
Both the absolute and relative numbers of the elderly have increased phenomenally. At the beginning of this century, persons aged 60 or over represented 1 out of every 16 persons in this country. They now represent about 1 out of every 9. or 11.6% (United States Bureau of the Census, 1984) and by the year 2030 will represent over one-fourth of the total population (Fowles, 1983).
Of even greater significance is the growth of the
really old, or as Neugarten (1974) calls them the "old-old" in our population. While the size of the population 60 and over has increased by over seven times since 1900, the
population 75 and over has experienced an elevenfold increase and the 85 and older age group has multiplied approximately 18 times. Currently, about one-fourth of the older population is 75 and older, and the proportion is expected to increase to over one-third by 2030. As for those 85 and older, while they now comprise about 1 out of every 16 older persons, by 2030 they are projected to represent 1 out of every 11 elderly (Fowlesr 1983).
Significantly, these "old-old" are the elderly who are most likely to be limited in their activities and/or confined to bed due to chronic physical and/or mental conditions. As reported by Fowles (1983), the results of the 1977 National Health Interview Survey indicated that when one breaks down the 65 and older age group into categories, while 9% of those 65 or older were so limited, the percentage rose from 5% for persons 65-74 to 12% for persons 7584, and 31% for persons 85 years and older.
As the elderly in general are more prone to utilize
health care services than the population at large, it is not surprising to note that the shift in our population is among the major causes of our rise in health care expenditures. However this is not the sole culprit. Other key factors include new medical technologies inflation, and an increase in the absolute numbers in our population. Between 1971 and 1981 health care spending in the United States more
than tripled, increasing from $83 billion to $287 billion. Moreover, projections place health costs in 1990 at roughly $756 billion which is approximately 12% of our gross national product (Freeland and Schendler, 1983).
Approximately $24 billion was spent on nursing home care alone in 1981 (Freeland and Schendler, 1983). once again, while the elderly as a group are disproportionately high users of nursing homes, in 1977 almost 5% of people 65 years of age and over were nursing home residents; the proportion was more than 20% for people 85 years of age and older (National Center for Health Statisticsy 1981).
Finally, modernization has lead to a restructuring of
the American family, with families becoming smaller and more mobile, and with more women entering the work force. For instance, while in 1960 only 34.8% of women were in the work force? in 1982 this percentage had risen to 52.1% (United States Bureau of the Census, 1984).
For the elderly this has meant that their families are less available to help meet their needs. A large study of the elderly living in the inner city of New York (N = 11552) found that over one-third of the respondents had no living children and another 11% had none that met the criterion of functionality i.e., that they had relatives living within the confines of the city who were seen or heard from regularly (Cantor, 1979). Furthermore, even when children are available, as the elderly continue to age, one is
increasingly faced with the situation whereby a 65-year-old "child" is responsible for caring for a 85-year-old parent. Cantor did demonstrate that to some degree when their family is unavailable the elderly are able and willing to substitute the services of friends and neighbors to meet their needs. However, the size of their personal nonrelative network also becomes increasingly restricted with age. In this same study the mean number of nonrelated friends reported was .68 and the mean number of neighbors known well was only 2.1.
Concern about the quality of life among the elderly and the high cost of institutional care has led to the exploration of alternatives to nursing home placement. As a part of this movement an intermediate continuum of living arrangements for those who no longer "fit comfortably" in private homes, but do not yet demand the level of care provided by nursing homes is emerging. Included in this intermediate range of housing alternatives are such living arrangements as retirement communities, home sharing, foster homes, elder cottages, share-a-homes, and adult residential care facilities (Habenstein, Kiefer, and Wang, 1976; Lawton, 1981; Streib, Folts, and Hilker, 1984). Along with these emerging environmental alternatives has come the pursuit of an attempt to match the elderly most appropriately with the available care alternatives. Thus, placement assessment
tools have begun to surface (Christ, Visscher, and Bates, 1985; Kleh, 1977; Sherwood, Morris, and Barnhart, 1978).
The Adult Congregate Living Facili-ty
The focus of this dissertation is on one particular type of adult residential facility, the adult congregate living facility (ACLF). Adult congregate living facilities are group living facilities which provide housing, food services, and one or more personal services for their residents. Personal services include such services as individual assistance with or supervision of essential activities of daily living--such as eating, grooming, dressing, and ambulation--and the supervision of self-administered medication.
A key difference between ACLFs and nursing homes is
that, unlike nursing homes, ACLFs are not required to provide professional therapy for their residents. Rather, they act in a paraprofessional manner "supervising" self-administered medications, arranging medical appointments when necessary, and reporting deviations from the resident's normal appearance and health to the resident's family, or primary health provider.
Nominal designations of the facilities presenting this type of residential care services vary from state to state with such alternative titles as homes for adults, board and care facilities, and licensed boarding facilities being
common. Additionally, standardized national licensing criteria are currently lacking. To date, these variations have prevented the compilation of national demographic statistics on the ACLF alternative. However, statistics have been compiled for Florida, which is the state where this dissertation was done.
Statistics indicate that the ACLF is far from an insignificant phenomenon in Florida. As of December 1984F there were 1,180 licensed ACLFs in Florida, housing 39,500 resident beds (Florida Office of Evaluation and Management Review, 1985). A total of 84 ACLFs exist in the Orange County area (District 7) alone (Florida Department of Health and Rehabilitative Services, 1985). Furthermore, there appears to be a large number of small operators serving less than four residents that are unlicensed, and therefore not included in these figures.
In Florida the average ACLF monthly fee is $545, with a range from $116 to $1,625 around the state. Interestingly, this is less than half of the cost of a nursing home bed, which averages around $1,500 (Florida Office of Evaluation and Management Review, 1985). Currently most of the costs are covered privately, as Florida only has designated enough resources to finance the expenses of 10% of these beds. Financing is accomplished by supplementing the resident's SSI payment to total $486, which is then paid to the ACLF operator.
Although ACLF living with its official rules and regulations and presenting accommodations of group life is generally more structured than private living arrangements, the ACLF is a relatively open institution. Generally, residents can come and go as they please without requiring medical permission. Private communication, including receiving and sending unopened correspondence, telephone access, and liberal visiting hours (usually defined as all waking hours), is also unrestricted. Additionally, its lack of medical staff may be perceived by the residents as contributing to its more "home-like" atmosphere. Certainly its cost savings alone make it attractive enough to be considered by those not requiring more extensive medical care.
Given the continuing need among the elderly for institutionalized care and the potential attractiveness of ACLF living as an alternative for those elderly who do not require the more intensive care of a nursing home or hospital, a look at the process by which the elderly come to enter an ACLF is both timely and necessary. While a fairly large body of literature exists on the process of mental institutionalization for adults (Brown, Birley, and Wing, 1972; Goffman, 1961; Greeley, 1972; Hammer, 1963; Horwitz, 1977; Perrucci and Targ, 1982; Scheff, 1966; Vaghn and Leff, 1976), the literature that looks at ACLF placement is quite
limited (Florida Office of Evaluation and Management Review, 1985).
The study of relocation of the elderly, a tangential and somewhat more encompassing concept than institutionalization per se, has been extensively studied. Yet, the bulk of this literature has focused upon the effects of interinstitution relocation on resident mortality (Aldrich and Mendkoff, 1963; Coffman, 1981; Gutman and Herbert, 1976; Markus, Bleckner, Blooms, and Downs, 1971). While a smaller component of this work does examine the effect of resident relocation on the resident's network and/or socialization patterns (Borup, 1982; Borup, Gallego, and Haffernan, 1976; Wells and MacDonald, 1981), that which directs itself toward the network determinants of this process is much more scarce (Allison-Cooke, 1982; Lowenthal-Fiske, 1964; Wan and Weissert, 1981; Wells and MacDonald, 1981).
The process of institutionalization is in effect a type of illness behavior. While illness behavior has been clearly differentiated from the state of being ill (Freidson, 1970; Mechanic, 1978), the variables which act to determine illness behavior remain under scrutiny. Both cultural and structural determinants have been identified along with the interrelationship between beliefs and social situations.
The Focal Problem
This dissertation focused on social network variables as primary structural variables influencing the process of ACLF entry. As defined by Hammer, Makiesky-Barrow, and Gutwirth (1978:523),
An individual's social network consists of his
or her direct social contacts, the relationships among them, and their relationships with others
who are not directly connected to the focal
individual. Such links may be thought of as
the basic building blocks of social structure;
and their formation, maintenance, and severance
are universal and fundamental processes.
In terms of the process of ACLF entry, five key variables were of interest: (a) the process by which a new resident came to be labeled as "out of place" in his/her former environment, (b) the process by which a new resident was referred to an ACLF, (c) the diagnosed severity of the new resident's health condition at the time of his/her move into the ACLF, (d) the effect of the move into the ACLF on the resident's network relationships, and (e) the probability of the resident's relocation to a private residence after ACLF placement.
Given that the relationship of these variables to the process of ACLF placement is virtually unexplored, the researcher built on the general findings that have emerged in terms of the relationship between network variables and health care utilization and institutionalization. A review of related research and theory indicated that both
structural and interactional network variables influence the process of health care utilization and institutionalization. In terms of network structure, density appears to be of central importance. In terms of interactional variables, the intensity and direction of network relationships are emerging as the critical variables. Thus, each of these variables were examined in terms of ACLF entry.
Explored were such questions as
--What are the characteristics of the resident
of an ACLF?
--What are the characteristics of the networks
of ACLF residents?
--How did the ACLF resident come to recognize
that his/her current environmental "fit" is
--How did the ACLF resident become informed of
--How do the residents and their networks
react to the ACLF move?
--What is the differential importance of the
elderly's formal and informal networks in the
--What happens to the new resident's previously
established ties after ACLF relocation?
--Once placed in an ACLF, what are the
resident's chances of remaining there? and,
--To what degree are these processes influenced
by network density, degree, and the intensity
and direction of network relationships?
Answers to such questions were sought via multiple
methods. A longitudinal design was used with a six-month lag between Time 1 and Time 2 data collection. Both the new
residents and their closest available other were interviewed via a combination of face-to-face and telephone contacts. Question formats included open-ended and close-ended questions and incorporated standardized measurement tools.
The theoretical basis for this dissertation is presented in the second and third chapters. Chapter Two discusses network analysis; its emergence and development and key conceptual components are outlined. Chapter Three then relates the concepts of network theory to the process by which a person comes to enter an adult congregate living facility. This relocation process is conceptualized as a type of illness behavior. In Chapter Four, the previous studies which are pertinent to this research are reviewed. The methodological approaches used in this dissertation are outlined in Chapter Five. Chapters Six through Nine present and analyze the results of the data collected at Time lF and Chapters Ten and Eleven analyze the results of the information collected at Time 2. Finally, a discussion of the theoretical and practical implications of this dissertation is outlined in Chapter Twelve.
Emergence and Development
Network analysis may be understood as an emerging theoretical framework. Its conceptual focus is on the nature and patterns of the "links" between people and the effects of these "links" on human behavior. Theoretical reviews of network analysis generally claim that its developmental movement has been from a metamorphical concept of social networks to an approach which has developed a concept of increased analytical clarity (Mitchell, 1969; Whitten and Wolfer 1973). Barnes (1954) and Bott (1957) are generally credited as being among the first to incorporate a more rigorous notion of social networks into their research. Both of these studies considered how the characteristics of sets of interpersonal links acted independently of personal attributes to influence the behavior of network members.
However, while this analysis is valid in so far as it
traces the utilization of the second-order construct, social networks, it fails in that it does not address the development of the meaning and method that has been associated with this abstraction (Berger and Kellner, 1981). Along these latter lines it seems justified to preface a review of some of the more recent developments in network analysis with a
brief mentioning of the similarities to network analysis foreshadowed in the works of Georg Simmel.
Simmel's work on social forms is amazingly similar in focus to the central interest in network analysis--the pattern and nature of the social links between people and the effect of these links on human behavior. A form is "the mutual determination and interaction of the elements of association" (in Wolff, 1950:44). In essence, then, Simmel's "form" is an analyzable social link between two or more individuals with a substance that stands apart from the unique characteristics of its component elements. It is a structure all of its own, a social structure which acts as an independent variable influencing human behavior. Under this method of abstraction Simmel proceeded to analyze such diverse links between people as conflict, intimacy, acquaintanceship, superordination and its companion, subordination.
Just as Simmel's work directed him toward analysis of the "countless minor syntheses" (in Wolff, 1950:9) of individuals in the course of their daily existence, so, too, has the work of social network theorists lead them away from such analytical units as religion, race, sex, and family. Rather than focusing on group delineations or "formal" social structures, social network theory focuses on the connections between people regardless of whether or not these connections fall within or cross these inert
boundaries. However, it is important to note, as Whitten and Wolfe (1973) so aptly point out, this theoretical focus does not simply leave for network analysis the social residuals, i.e., that which remains after "formal" social structures are parceled out for analysis. Rather, "network analysis provides the investigator with pathways into the heart of social systems whether or not the social systems have pronounced, formal, perpetuating structural arrangements with corporate, exclusive characteristics" (Whitten and Wolfe, 1973:719).
In addition to being interested in analyzing the nature of social forms Simmel also focused on how other social variables acted to influence the patterns of human interaction; i.e., he was looking at how social factors influenced the structure of social networks. An exemplary work in this vein is Conflict and the Web of Group Afiations (Simmel, 1955). In this essay, Simmel demonstrates the influence of modernity on the process of group affiliation. A primary consequence of this process of modernization is identified as social differentiation. With social differentiation, association becomes based upon common purpose rather than propinquity. Our social circles, thus, lose their concentric formation and become crosscutting circles; i.e., the structure of our social networks changes. Here as in network analysis, Simmel is examining how the nature of social links is affected by broader social
changes. In this case, however, rather than looking at the characteristics of a given type of dyadic link, Simmel's focus extends to the pattern of links that characterizes an individual's social environment.
Barnes' (1954) and Bott's (1957) observations about the consequences of modernity on social networks are remarkably similar to those introduced by Simmel. For instance, Barnes (1954:44) states, "One of the principal formal differences between simple, rural, or small-scale societies as against modern, civilized, urban or mass societies is that in the former the mesh of the social network is small, in the latter it is large." Similarly, Bott (1957:100) remarks, "Whereas a family in a small-scale, relatively closed society belongs to a small number of groups each with many functions, an urban family exists in a network of many separate, unconnected institutions each with a specialized function."
While Barnes and Bott did not recognize the connections of their work to Simmel's, Blau cognizantly draws from Simmel's work as he analyzes the effects of social structure on patterns of interaction (Blau, 1974; Blau, Blum and Schwartz, 1982; Blau, Beeker, and Fitzpatrick, 1984). Like Simmel, Blau recognized that patterns of cross-cutting circles would affect intergroup relationships in a society. In fact, Blau's work, "Intersecting social affiliations and
intermarriage" (Blau et al., 1984) is an explicit test of this theory. Intergroup relations were demonstrated to be a direct consequence of cross-cutting circles. Although Blau does not relate this phenomenon to one's social network, it can be seen how he is in effect describing how broader social changes have the independent consequence of affecting the pattern of interpersonal affiliations, and, thus, of changing social networks.
Network analysis can focus on the morphological characteristics of networks and/or interactional network variables. As delineated by Mitchell (1969:12), "the morphological characteristics refer to the relationship or patterning of the links in the network in respect to one another." They focus on the set of relationships included in the network of interest. Included under this category of analysis are the following concepts: anchorage, range, density, and degree. In contrast, interactional criteria focus on the dyadic links that comprise any given network. Interactional criteria include content, directedness, durability, intensity and frequency. While interactional criteria include qualitative as well as quantitative dimensions, a network's morphological properties are solely quantifiable variables. Furthermore, as pointed out by Hammer (1981), unlike qualitative variables whose first order
meaning is culturally and hence situationally bounded, morphological network properties are "socially neutral" (Hammer, 1981:47). Hence, they can be used to compare networks across person place, and time.
A network's anchor is its point of reference (Mitchell, 1969). It is the organizing focus of the network. The selection of the anchor, or egor is usually guided by the researcher's interest in explaining the relationship of ego and ego's network to their presented behavior.
Network range simply refers to the size of the network. If researchers are interested in analyzing network range they must be able and willing to identify a bounded network. While in theory the concept of social network can be extended to describe all of the links between persons in a given society (Barnes, 1954) realistically, to be analyzable a network must be delimited. In addition to anchorages other methods of network delineation include content specification and the determination of the focal social distance between ego and alter. In general, content refers to the nature of the interactional link between ego and alter. The concept of content is useful in that it gives us another way of working with an analyzable portion of the total social network. The concept of social distances indicates whether the links between ego and alter are direct or indirect.
Density and degree are different indicators of network interconnectedness. Density is a measure of network
completeness. It is the proportion of the theoretically possible direct links that exist in a particular network (Barnes, 1969), and, thus, is a structural measure of network bondedness. For a network, unlike a group, does not demand a coordinating organization among its members "only some, not all of the component individuals have social relationships with one another" (Bott, 1957:58).
The concept of degree focuses on the average number of people in a network who are connected. It indicates the average number of people who are bound together. Hence, degree refers to the size of a completed network rather than the extent to which a network is completed.
Controlling for network size, density, and degree are directly related: as degree increases, so does network density. However, when analyzing networks of disparate sizes, if the networks have the same degree, the larger network will have a lower density than the smaller network. Furthermore, two networks with the same density may differ substantially in their number of actualized relations due to differences in their total numbers (Barnes, 1969; Neimeijer, 1973).
In contrast to morphology, which describes network
attributes, interactional network characteristics delineate linkage attributes. Included in this category of analysis
are the following variables: content, directedness, durability, intensity, and frequency.
While the notion of content is critical in network
analysis, its meaning is not consistent throughout the literature. In general, content may be understood as that which determines any given interpersonal link. However, from this starting point much confusion exists in the literature. Two basic directions can be followed. The first, as outlined by Mitchell (1969), focuses on the normative context in which interaction takes place. En this vein, links are broadly defined in such categories as kinship, friendship, and coworkers. The second direction, which is more commonly found in the work of researchers focusing on interpersonal communications (Epstein, 1961; Kapferer, 1969; Sokolvosky, Cohen, Berger and Geiger, 1978), analyzes content in terms of social exchanges. Here one speaks of links in terms of specific behaviors, i.e., visiting and conversation, advice, medical aid, and loan rendering. Such transactional content can be further delineated in terms of material and nonmaterial content (Cohen and Rajkowski, 1982).
At issue in these varying approaches to operationalization of the concept, content, appears to be the degree to which researchers abstract from given behaviors to a category of behaviors to which a sociological meaning is
applied. Those that focus solely on content in terms of basic exchanges refrain from imposing any meaning to the behaviors of actors. In so doing, they avoid what Berger and Kellner (1981:40) term the problem of "meaning adequacy.n Howeverr they also avoid any conceptualization of exchange relationships.
This is not to say that an exchange framework invariably prevents conceptualization of behavior. It is possible to begin one's research by identifying these specific interpersonal links and then work to give them a more abstract sociological interpretation. This is attempted in the work of Bott (1957). While Bott does not specifically address the notions of content or of interpersonal exchanges, she does speak of varying social distances in kinship relationships. Four qualitative categories are outlined: intimate relatives effective relatives, noneffective relatives, and unfamiliar relatives. Categorization is based upon the existence of specific social exchanges in relationships. For example while intimate relatives visited frequently and engaged in mutual aid, noneffective relatives shared few social exchanges. Only knowledge about such gross facts as the relative's name and occupation is necessary.
Wellman (1981) followed a similar strategy in his follow-up study on the personal communities of East New Yorkers. Extensive data were collected on the nature of the links comprising any one interpersonal network tie. "Tie
types" were then categorized according to contact frequency tie content, and tie intimacy into five nonexclusive categories: active, intimate, sociable, routine, and supportive. Information on personal, phone, and written contact was obtained, with an active contact being defined as at least one contact in the last year. While tie intimacy was determined rather loosely by the respondent's definition of the link as being "close," extensive information was gathered on the type (personal service, material, emotional, and informational) and direction (instrumental, dependent, and reciprocal) of support. All ties who gave the respondent at least one type of aid were classified as supportive.
Those with a normative focus do categorize links in
terms of patterns of behavior. At risk here is whether the sociological interpretation of the behaviors is consistent with the meanings the actors themselves impose upon their behaviors. Often discussed in this vein is the conceptualization of friendship. Bott pinpoints this clearly in her second edition of Family and Social Network (1971:244):
The definition of "friend" is an important empirical
problem. I think it best to start by using the
definitions of one's informants; in questionnaire
studies one should also remember that "friend" may
mean very different things to different people.
Regardless of the approach taken by network theorists to content delineation, there is general agreement that
persons can be bound by variable numbers of links. As introduced by Gluckman (1955), networks which contain only one focus of interaction are called "uniplex" or more simply, single-stranded relationships. Similarly, those which contain more than one content are called "multiplex" or many stranded relationships.
Disagreement exists as to the degree to which multiplexity is correlated with the strength of an interpersonal relationship. As presented by Kapferer (1969:213) "Multiplex links are stronger than those of uniplex." Bott, too, seems to indirectly agree with this assertation as she finds that as the number of links between kin increases, so does the strength of their relationship (1957). This position is countered by Granovetter (1973:1361), who contends that while in some cases multiplex relations may indeed be strong, "ties with only one content or with diffuse content may be strong as well." This argument is particularly relevant because it is generally agreed that while multiplexity is a common feature of interpersonal links in rural societies, modern societies tend to be characterized by uniplex interpersonal links (Barnes, 1954; Bott, 1957; Simmel, 1955).
While content refers to the basis of an interpersonal link, directedness indicates whether or not the meaning of the tie is shared between the parties of a dyad (Mitchell, 1969). If the quality of the relationship varies depending
upon the direction of the interaction, the tie is asymmetric, or one-sided. An instrumental tie is one in which the content flows only from ego to alter. A dependent tie is one in which the content of the tie flows only from alter
to ego (Sokolovsky et al., 1978). Conversely, in symmetric ties the content between the parties is shared.
While the concept of tie symmetry is often interchanged with that of tie reciprocity, reciprocity has a somewhat broader meaning. As defined by Gouldner (1960:164), a reciprocal tie is one characterized by a "mutually contingent exchange of benefits." Thus, a tie is reciprocated as long as the content exchanged between A and B is perceived as roughly equivalent by both parties. Symmetry, on the other hand, only exists when the content exchanged between A and B is perceived similarly between both parties. Thus, while a symmetric relationship is always reciprocal, a reciprocal relationship is not always symmetrical.
Both reciprocity and symmetry have been proposed to
affect other interactional qualities of a relationship. As early as 1960, Gouldner (1960:164) posited that "reciprocal relations stabilize patterns." Similarly, in her discussion of social distance, Hammer (1963) suggests that when intimacy is shared between parties their efforts to maintain the relationship will be greater than if intimacy is only
one-sidedly exchanged. Thus, in both of these cases linkage durability was proposed to vary with linkage directedness.
More recently, Wentowski theorized that the role reciprocity played in relationships was normative, "something received requires something returned" (1981:602-603). Return services may be either immediate or delayed, with delays serving them to build up credit for the giving toward services they may require in the future.
A review of network theory leaves one groping for a
clear and consistent conceptualization of tie intensity. In effect, intensity is a component of content as it is a measure of linkage variability. More specifically, intensity may be understood as an indication of the strength of a particular link. Yet from that point one finds much disagreement as to just what a "strong" or "intense" tie is.
Epstein (1961) seems to relate Bott's (1957) previously discussed notion of social distance to intensity, indicating that intense or effective relationships involve a high degree of interpersonal "closeness" and interactional frequency. Yet, while his work alerts one to the importance of identifying this variable, his operationalization of the concept is too vague to be useful.
In a later work Wheeldon (1969) refines Epstein's notion of intensity, positing that intense or effective relationships are many "stranded" or multiplex. Wheeldon goes
on to say that effective relationships tend to be confined to ego's peers, are likely to persist despite vicissitudes, and include the people with whom ego gossips with most freedom and intensity, and with reference to the explicit formulation of moral norms (1969). Thus, once again, multiplexity is conceived as a component of intensity. Also implicit here are the component elements of intimacy and reciprocity.
In his discussion of intensity, Mitchell (1969:27) also emphasizes the dimension of tie reciprocity as a key element in relationship intensity: "The intensity of a link refers to the degree to which individuals are prepared to honour obligations or feel free to exercise the rights implied in their links to some other person." Here it needs to be pointed out that both Mitchell (1969) and Gouldner (1960) have suggested that obligations to return services can extend over long periods of time. Thus, even if at present there is infrequent communication between ego and alter, upon the surfacing of a need on the part of ego, if obliged, alter is likely to respond to that need to reciprocate for former services on the part of ego.
Granovetter's (1973) more recent conceptualization of tie intensity or strength is a good synthesis of preceding efforts. "The strength of a tie is a (probably linear) combination of the amount of time, the emotional intensity, the intimacy (mutual confiding), and the reciprocal services
which characterize the tie" (1973:1361). So understood intensity is a multiple-dimensioned abstraction with both qualitative and quantitative components.
The final interactional component mentioned in network theory is frequency. While its measurement is probably the most straightforward, its meaning is somewhat confusing. All relationships marked by frequent contact are not intense or strong. As pointed out by Mitchell (1969:29), "Contacts with workmates may be both regular and frequent, but the influence of these workmates over the behavior of an individual may be less than that of a close kinsman whom he sees infrequently and irregularly. . ." Yet, it is recognized that some minimal frequency of contact is necessary for meaningful inclusion of another in ego's network. Furthermore, this minimal level of contact is likely to vary from one situation to another depending on operating social expectations.
Thusr network analysis needs to take into account both the global or morphological properties of networks and the properties of the particular dyadic ties or linkages within a given network. As noted by Lincoln (1982:4),
The distinction between properties of dyadic
tiesp evaluated separately and global
properties of whole networks is particularly
important. While networks are built from the configurations of ties between pairs of nodes,
most analysts view the whole, in this case,
as irreducible to the sum of the parts.
NETWORK VARIABLES AND ACLF RELOCATION Labeling and Referral
Relocation into an ACLF is the outcome of an interactive process. Through interaction with others the behavior of potential ACLF residents becomes redefined or labeled as indicative of a state incongruent with their current living situation. This is usually due to a perceived increase in their dependency as a result of recognized physical and/or mental health declines. Whether or not their behavior is actually "out of place" is not the critical element. Rather, it is the interpretation or imputation of a deviant meaning to this illness behavior that is of central importance.
The initial redefinition or labeling of behavior may be imputed by the potential ACLF residents a key network member, or by a health professional. Furthermore, even acts committed outside of the range of others may be self-labeled as deviant. Due to the reflexive nature of self (Mead, 1977), people are able to engage in interactive dialogues with themselves. Either potential or committed acts can be compared with internalized general community stereotypes and anticipated reactions of potential others. The result may or may not be the imputation of deviance to a phenomenon.
Network variables are likely to be important predictors of the source of the initial "problematic" label to the potential ACLF resident's behavior. In terms of network structure or morphology, network density is of central importance in determining labeling behavior. As posited by Granovetter (1973, 1981) and Horwitz (1977), the degree of openness or density in ego's network is directly related to the number of different information channels which connect to ego. Weak ties link. They facilitate the spread of novel information to ego. Thus, an open network is likely to be more diverse in its attitudes and knowledge base. Hence, an open network is more likely to have the knowledge necessary to recognize and label ego's behavior as a problem. Alternatively, if ego's network is dense it is less likely that network members will recognize ego's condition as a "problem." Rather, it is more likely that ego's problem will be so labeled by a professional outside of ego's personal network.
The intensity of ego's relationship with network members is the primary interactional variable related to labeling behavior. The existence of intense or strong ties implies a positive degree of emotional bondedness, instrumental reciprocity, regularity, and duration in relationships. This, in turn, is likely to be related to willingness or sense of obligation to "do for" ego (Gouldner, 1960;
Horowitz and Shindelman, 1983) and hence to network members' tolerance level for ego's behavior.
It is possible that either willingness or a sense of obligation "to do for" ego will be present if ego shares a reciprocal relationship with network members, regardless of the intensity of that relationship. As outlined by Gouldner (1960:170), "the generalized norm of reciprocity evokes obligations towards others on the basis of their past behavior." The balance of exchanges may be based on material and/or nonmaterial links. Additionally, the perception of the parties to a relationship that "over the long run" the balance of exchanges has been equivalent is also important.
Thust if ego's network relationships are intense,
marked by concern and tolerance, or if alter and ego merely have a reciprocated tie, network members are likely to attempt to cushion ego's declining physical and/or mental state and thus provide for a better balance or fit between ego and his/her environment. As network members are busy directing energies toward making the situation work, it is not as likely that they will be the ones to identify ego's "fit" as problematic. A professional is then the most likely person to recognize and label ego's state as "problematic." Alternatively, in a less intense or asymmetric relationship network members are more likely to label ego's condition as "problematic" and work toward ego's relocation.
Once the behavior of the potential ACLF resident is
defined as "out of placer" the tendency exists for his/her identity to be redefined as one who is "too sick" to remain in his/her current living situation. As pointed out by Freidson (1970) in the case of illness behavior, if major changes in self-identity and role expectations are to occur, the illness must be judged to be serious. Then the meaning of the act comes to be associated not with just a behavioral pattern of the actor; rather, this behavioral patterns or roler comes to be the dominant role by which the individual is identified. Lemert (1951) conceptualizes this transformation of self as the movement from a primary, or situationally bound definition of deviance to a state of secondary deviance where self-definitions of deviance affect all of one's behavior patterns. In effect, the sick role becomes the "master status" (Becker, 1963) of the potential ACLF resident.
Both past and future actions of the labeled deviant are then interpreted as components of this sick role. Past events are retrospectively interpreted to support the attribution of the new label (Schur, 1971). Future actions are anticipated to be deviant--and they are likely to be so. The power of suggestion (particularly by those in our immediate social world) is great. As others come to define people, so they tend to define themselves. The prospective
ACLF resident thus comes to see himself/herself as "out of place. "
The degree to which this phenomenon occurs will be
influenced by the degree of permanency imputed to the sick role assigned to the potential ACLF resident. As outlined by Freidson (1970), diseases can be perceived as acute (conditionally legitimate) or chronic (unconditionally legitimate). In making this distinction Freidson refined Parsons' notion of illness behavior (1968) While Parsons believed that the imputation of all types of illness behavior carried the obligation for the "imputee" to pursue a return to a healthy status, Freidson stated that only illnesses judged to be acute carried this expectation.
Thus, acute illnesses are conditionally legitimate,
with the "imputees" being excused from their social obligations and given extra privileges as long as they are working on returning to healthy behavior. Chronic illnesses are reacted and responded to differently. By their very definition, chronic illnesses are not deviations which one is expected to be able to shake. Rather, they are expected to be permanently associated with the "imputee." Social reactions, thus, are relatively unconditional on self-efforts to return to a healthier state. Therefore, while states imputed as chronic do carry future role definitions, acute conditions are much more temporary in duration.
Once illness is recognized, the potential ACLF resident's illness behaviors may be organized in a highly variable manner, even in similarly perceived conditions. As Freidson (1970:286) so aptly outlines, "Believing oneself to be ill does not in itself lead to the use of medical services." Illness behaviors may be unattended, self-attended, or help may be sought from others.
In our culture physicians tend to be regarded as the primary healers of illness and hence the ones to be sought if one is believed to be suffering from a disease. The physician can respond to requests for help by controlling or reversing the potential ACLF resident's physical and/or mental health decline, thus possibly changing the perception ,of his/her state so it is no longer recognized as being "out of place." Howeverr it is also possible that the physician's response will not lead to a redefinition of the potential ACLF resident's illness behaviors. In this case the physician may recommend to ego or members of ego's network that ego be relocated from his/her home into another environment. It is at this point that the physician may refer ego to an ACLF.
However, it is just as likely that ego or one of the members of ego's network will be the one to approach a physician requesting the screening examination required to allow ego to enter a given ACLF. In this case ego or a key network member is already knowledgeable about this option
and is simply using the professional to legitimize ego's relocation.
Once again, the density of ego's network is theorized to be a key determinant of these variable sources of ACLF referral. Currently, receiving information concerning relocation of the elderly once they are perceived no longer to "fit" in their current living situation is relatively problematic. While the nursing home option is commonly known other more recent alternatives such as the ACLF are more elusive. However, as the density of ego's network is directly related to the number of different information channels which connect to ego (Granovetter, 1973, 1981; Horwitz, 1977) if ego's network is open, it is much more likely that a network member will be knowledgeable about ACLF's and hence be able to refer ego to an ACLF for resolution of his/her problem. On the other hand, if ego's network is relatively closed or dense, it is likely that this information will be transmitted by a professional rather than a network member.
llneas and Illness Behavior
While often used interchangeably, the notions of illness and illness behavior are conceptually different. In our culture, behavior that is perceived to be biologically deviant is labeled illness. In other words, illness is that phenomenon which deviates from what is judged to be healthy
or normal acts or attributes for a given individual. Alternatively, illness behavior is the response of a given individual to what is perceived to be a biological deviation. While illness behavior is related to illness, other key variables affect the response of an individual to any particular disorder. Thus, for similar biological deviations one might witness very different illness behaviors between individuals. This argument is also valid in terms of the perception of others to any disorder of ego's. Thus, as was discussed, for the same biological disorder the response of ego's network members will vary in terms of labeling and referral.
Given this scenario, it is likely that the severity of ego's disorder will be highly variable at the time of ACLF referral. As network density, intensity, and reciprocity influence the referral process, it is also likely that they will affect the severity of ego's health at the time of referral. This is likely to be a direct positive relationship. While high network density results in referral delays due to a lack of information for problem recognition and help seeking, intense or reciprocal network relationships delay help seeking due to the willingness of network members to "do for" ego. This delay in recognition and referral is likely to result in a worsening of ego's condition at the time of recognition and referral.
Furthermore, as discussed by Hammer (1963:244), a dense network structure facilitates intranetwork support for members struggling to maintain ego in his/her current living situation. In essence, "the effects of the patient's behavior may be shared, thus creating less pressure for the severance of ties." Density also plays a role in the pressure felt by network members to conform to obligations incurred through past exchanges in a relationship. This is argued by Bott (1957) as she explains the relationship between tie interconnectedness and conjugal role separation. "If kin see one another frequently, they are able to put consistent, almost collective pressure on a family to keep up kinship obligations" (1957:60). However, the ease of intranetwork communication will vary with link reachability. Two networks with the same density may have different rates of communication due to differences in their linkage patterns.
Upon relocation to an ACLF, the redefinition of ego's dependency state is complete. The independence of family life is shed. Privacy is greatly diminished and life tends to be regimented according to the convenience of others. While an ACLF does not fit Goffman's (1961) definition of a total institution, the ACLF resident is faced with a shared living environment with a set of formalized and informalized
rules. In their discussion of "Share-a-Homesf" Streib et al. (1984) describe this type of living situation as an amalgam, something midway between institutional and family life.
To some degree, ego's ACLF residency will become a major source of both ego's self-identity and of the way he/she is perceived by others. No longer will ego be recognized as an independent individual, one who can do for one's self. As ego's identity changes, so will his/her network's expectations for ego's behavior. This can result in changes in the balance of exchanges in relationships. Ego may no longer be able to contribute his/her fair share in the balance of "give and take."
Ego's network can respond to this situation by either abandoning ego or by readjusting their expectations of ego, but still maintaining network ties. Both the nature of any given network link, and the structure of the network itself appear to be central variables in this regard. In terms of network interactional variables, intensity and reciprocity are most likely to relate to the duration of ties after ego is relocated into an ACLF. In both cases the relationship is posited as positive and direct. Intense relationships have "a lot going for them." Included are such things as time, emotional bondedness, and reciprocated material exchanges. In this case it is likely that the depth and breadth of the relationships will compensate for ego's
identity changes. Alternatively, reciprocal relationships do not necessarily involve emotional bondedness or long standedness on the part of its members. If ego has not obligated network members through past services and/or can no longer reciprocate alter's exchanges, it is likely that the relationship will be abandoned. Thus, it is proposed that if a uniplex tie becomes symmetric, it is less likely to endure.
The key structural variable affecting tie duration is density. Once again, the relationship is posited as positive. As outlined by Hammer (1963) and Hammer and Shaffer (1975), there are at least three reasons for this relationship: (1) The formation of dense networks demands more time and energy than the formation of open networks, hence members have "more to lose" if the network is disorganized;
(2) due to its interconnected structure loss of a member will demand complete reorganization on the part of a dense network; and (3) density allows for greater intranetwork support and pressure for norm enforcement, thus facilitating the continuation of ties with ego.
Relocation to Hom
Once applied, the definition of deviance is particularly hard to shake. Hawkins and Tiedeman (1975) identify this as the problem of return. Access to conventional roles is limited, and all behavior tends to be suspect. In terms
of the ACLF residents this implies that once the transition from one's home has been completed there is a low likelihood of returning. While this is true regardless of whether or not ego maintains primary network membership, return is predicted to be particularly unlikely if network ties are broken. Thus, while network tie maintenance is identified as a necessary condition for return, even if ties are maintained ego's return home is still unlikely.
As previously discussed, tie duration is positively
related to tie intensity, tie reciprocity, and network density. This same relationship holds for the severity of ego's health at the time of ACLF relocation. Thus, enduring ties are most likely to exist when ego's presenting condition is less healthy. This implies that under these conditions ego's relocation to an ACLF was probably delayed until no other alternative was possible for the network. Notwithstanding an improvement in ego's condition, relocation is only likely if network normative pressure is great enough to result in the further network behavioral adjustments necessary for ego's move out of the ACLF.
Alternatively, while ego's presenting health status is likely to be better at the time of ACLF relocation, if his/her ties are not intense or reciprocated and ego's network is relatively opent the conditions that lead to what may be perceived as "premature" placement are not likely to
be altered during ego's residency. Thus, regardless of the nature of ego's network once ego is placed in an ACLF, relocation to his/her home or that of a network member is unlikely. Rather, if relocation is to occur, it will probably be to an institution which provides ego with more intensive health care, such as a hospital or nursing home.
In conclusions after reviewing the emergence and development of network theory and outlining the key components in this framework, network variables were related to the process of ACLF relocation. Tie intensity, tie reciprocity, and network density were identified as being centrally important in this regard. Their effects on "problem" labeling and referral, the severity of ego's presenting condition, the duration of ego's ties after ACLF placement, and the probability of ego returning to his/her home or the home of a network member were outlined. A review of the research that has addressed these relationships follows.
A key early study that examined the influence of network variables on the process of mental institutionalization is Muriel Hammer's 1963 study, "Influence of Small Social Networks as Factors on Hospital Admission." Sampled were 55 young and middle-aged adults admitted to Bellevue Psychiatric Hospital. Survey data were obtained from both the patient and several of his/her network members, with data from the person closest to ego considered as the basic source of information.
Three hypotheses were tested and supported with chisquare tests: (1) Patients in critical positions in their network are hospitalized more rapidly than those in noncritical positions. (2) Patients with nonsymmetrical ties are less likely to be given assistance in ways which may disturb the functioning of other members of the unit and/or to have therapy or hospitalization initiated. (3) Tie severance (cessation or sharp diminution of contact) is less likely for triangular than linear ties.
Five key points bear mentioning. First, it appears that hospitalization was perceived as a form of help rendering, a conclusion which may or may not be valid.
While this may explain why hospitalization was included as part of the dependent variable, assistance given prior to admission, this inclusion seems inappropriate as these may be indicators of two different types of behavior--help rendering and abandonment of ego. Second, as the notion of tie criticalness is used to express the existence of important instrumental ties from ego to alter, it is really a measure of tie directedness. Thus, there is some evidence that if ego has a key instrumental tie with alter, hospitalization is likely to be more rapid. Third, while the seriousness of ego's health status is not tested, duration can be posited to be directly related to seriousness. Furthermore, as Hammer's measure of duration was admittedly arbitrary, due to the complexity of preadmission symptomatology, seriousness at admission is possibly a more valid and reliable variable. Fourth, as used by Hammer, symmetry is a measure of mutual emotional bondedness to the degree that the persons involved in the relationship have no other ties which are closer. Thus, it is a lack of mutual emotional bondedness that limits network help rendering activities. And fifth, while Hammer uses the notion of triangular vs. linear ties instead of density, their meanings are similar. Thus, tie severance was found to be negatively related to tie density.
While Lowenthal-Fiske (1964) did not incorporate carefully defined network characteristics into her study on the process of mental hospitalization for the elderly, she did look at the differential effects of variations in social living arrangements (isolation, living alone, living with a spouse or one's children, or living with other relatives) on this process. Sampled were 534 elderly San Francisco residents admitted to psychiatric wards and 600 nonhospitalized elderly San Francisco residents. In terms of the process towards hospitalization, data on predisposing factors were gathered from the person or persons best informed about the patient. Semistructured, open-ended interviews were used, with 56% of these interviews taking place in person and 44% occurring over the telephone.
In general, hospitalization was preceded by a long period of illness for the patient, during which time a variety of prealternatives were attempted. Interestingly, the social living arrangements of the patients were shown to have a greater influence on the course of hospitalization than were social class variables. Key differences were identified between isolates, those living with close relatives, and those living with distant relatives. Distant relative relational systems were less likely to try prealternatives, had less tolerance for symptoms, and acted most quickly to hospitalize the patient. Thus, patients
from this type of network presented with less serious symptoms at the time of admission. Interestingly, the most serious behaviors tended to be presented by isolates, possibly due to the fact that they were publicly ignored until their condition was perceived as harmful to themselves or others.
Precipitants were easily identified, with all but 23 informants being able to isolate the factor that caused someone to conclude that the patient no longer belonged in his/her current environment. However, information as to the source of this initial label was not compiled.
In terms of the referral process, the role of physicians was extensive, with their participating in at least three-fourths of all cases. However, a difference was noted in the source of the initial action, with personal or informal network members being responsible only 50% of the time. Correlates of this variable were only roughly identified. Among patients living with others, the first action was most likely taken by those with whom they lived. Not surprisingly, for isolates the first action comes from formal sources.
Once admitted to the psychiatric ward community discharge was unlikely, with only 15% returning home. Of significance here were the complexity of predisposing factors, the duration of the condition, and the number of prealternatives tried.
Tobin and Lieberman (1976) examined both the process by which the elderly enter a long-term care institution and the effects of that decision on the elderly's physical and mental well-being. The study design was longitudinal and incorporated community-based controls. Only mentally and physically able elderly were included in the sample (N = 88). These elderly were found to be the primary agents controlling institutional entry, with family and social service personnel assisting in this process. While negative consequences of institutional entry were, in some part, explained by passivity and relocation, the primary negative health "effects" were shown to be characteristics that were already present in the new residents prior to their instutionalization.
In a more limited study, Smyer (1980) also analyzed
some key variables that discriminate between institutionalization and community care of the elderly. Studied were 33 client pairs (one from an intermediate care facility and one from a home care program) matched according to their level of functioning. Survey data were collected from the client, staff, and a family member or friend.
Analysis indicated that the family's reported ability to care for the client was the primary key to avoiding institutionalization. Yet, poor client mental health and the number of previous contacts with other service agencies in the community were significant counter forces.
Interestingly, poor mental health rather than physical symptomatology was most stressful to the care-taking child, and, thus, in Lowenthal's terminology was a key institutionalization precipitant. The other counter force, number of community service contacts, implies that institutionalization was preceded by a complicated process of searching for other alternatives. This is highly suggestive of the perception of the institution as the "option of last resort" rather than the help-rendering activity defined by Hammer (1963).
McKinlay (1973) explicitly examined the effects of social networks on lay consultation and help-seeking behavior. Interviewed were 87 unskilled working class families (this was identified as an attempt to control for class variables), 48 of which were classified as underutilizers of maternity care and 39 of which were classified as utilizers. In essence, underutilizers rejected early prenatal care, using formal health services only in the end stages of their pregnancies when their "need" or the seriousness of their condition was the highest.
Information was collected about specific network fields (i.e., kin and relatives) and about the total primary network (kin plus relatives). The tests used were the t-test for continuous data and the cumulative chi-square test for categorical data. Several key trends emerged. Regular
utilizers of prenatal services visited with their relatives less frequently, perhaps indicating greater independence and/or intensity in their kinship network, and had a higher frequency of contact with their friends. Furthermore, utilizers appeared to have separate or differentiated kin and friendship networks, implying that their total networks were more open than the networks of nonutilizers. Thus it was shown that those utilizing maternity services when their condition was less serious had less contact with their relatives and more contact with what was identified as a differentiated friendship network.
McKinlay also explored the source of consultation for various problems. In terms of health problems, key differences emerged between utilizers and nonutilizers, with nonutilizers more likely to consult with their mothers or siblings for possible solutions and utilizers more likely to consult with nonrelatives and friends. However, as a rule, utilizers were less likely to consult with any primary network members before visiting a physician for recognized health problems in their children. In conclusion, McKinlay found some evidence that those maternity clients with an open friendship network and less intensive family network were more likely to define their "health problem" in medical terms and had an increased likelihood of an early referral, or medical visit.
Horwitz (1977) also examined the relationship of network variables to the help-seeking process. Labeling, referral, problem severity, and problem duration were the dependent variables examined. Additionally, like Lowenthal? he attempted to compare the variable effects of network and cultural variables on the help-seeking process. In this vein, he subcategorized his sample of 120 patients at a community mental health center into members of social classes III and IV--the middle and working classes on the Hollingshead index. While the patients were the primary data source, a number of their network members were also interviewed to serve as reliability cross checks. The patients medical records were examined for this same purpose.
Like McKinlay, Horwitz segregated ego's primary network into fields and collected both subnetwork and total network data. Once again, a frequency measure was used as an indicator of family network strength or intensity. Similarly, as in the McKinlay study respondents' self definitions were used to determine their friendship network; however, in this case only ego's three closest friends were included. Thus, friendship measures were based upon this self-defined, abbreviated friendship network. Testing was done via multiple regression analysis, with categorical independent variables treated as dummy variables.
In general, while there was a tendency for people with strong kin groups and closed friendship networks to be insulated from formal labels, no significant findings emerged in terms of either network or cultural variables and the labeling and referral process. However, when network members were further identified as communicating either positive or negative information about psychiatric treatment, it was shown that having a "positive" network member was positively related to informal labeling and referral. Thus, it was not enough for ego's network to be open and thus more likely to be informed of psychiatric care, the network also had to communicate positive information to ego about these services.
Although Horwitz did not pursue his data to this point, these results hint at a possible interactive effect between network variables and cultural variables,- i.e., controlling for the quality of information received by ego (positive or negative), the strength of association between density and informal referral will vary. If the information received is positive, there is likely to be a strong positive association between network openness and informal labeling and referral. However, if the information received is negative, this association is likely to be weaker or insignificant.
Stronger findings emerged in terms of social network variables and the severity of ego's presenting condition. When ego had strong kin and closed friendship networks,
treatment was delayed until symptoms became severe. Interestingly, the relationship between class variables and severity was insignificant. As explained by Horwitz
(1977 : 96-97) ,
The strong kin group supports the person within the
primary network while closed or absent friendship structures make information about psychiatry less
accessible. This group is the most likely to enter treatment after dramatic incidents such as suicide
attempts or psychotic breaks. On the other hand,
people with weak kin groups and open friendship networks do not receive strong internal support
but have the ability to connect to psychiatric
resources and they readily enter treatment with
The findings in terms of duration were somewhat confusing: (1) There was no relationship between social class variables and duration. (2) Persons with weak kin networks and open friendship networks entered treatment most rapidly.
(3) Persons with weak kin networks and closed friendship networks had the longest duration of symptoms. (4) Persons with strong kin networks and closed friendship networks had a duration approximately equivalent to the sample mean. However as the method of determining these data was not explained, one's interpretation can only be based on assumptions. More than likely, inaccuracies in duration data account for most of the confusion in these results. As pointed out in the Lowenthal-Fiske (1964) study, the complexity of preadmission symptomatology is significant, with involvement of both predisposing and precipitating factors.
Thus, reliable and valid duration data can only be gleaned from careful specification of the source from which duration will begin to be computed.
Perrucci and Targ (1982) also studied the process of mental institutionalization from a network perspective. Specifically examined were the processes of labeling and referral as functions of network density, size, and intensity. A small sample of the networks of 45 hospitalized persons was interviewed to enable data collection from all identified network members.
Concept operationalization was unconventional. Density was based on frequency of contact, not on the proportion of theoretically possible direct ties. Openness, measured separately, was measured by number of existing ties with nonfamily members. Finally, closeness or intensity, was considered as a nominal variable, with a network categorized as nonintense when the same person was not nominated by network members more than once as having close ties with ego. The two conflicting measures of density are confusing, and although neither is consistent with measures used in other studies, as the later seems more in tune with the theoretical meaning of the concept it will be used in result summarization.
Similar to previous findings, those patients with
small, closed networks tended to be insulated from formal labels. Furthermore, their networks were slower to seek
help, resulting in longer symptom duration prior to hospitalization. Alternatively, those with open networks were more likely to define their health problems in medical terms and seek early hospitalization.
In terms of network intensity, Perrucci and Targ's findings support results obtained by Hammer (1963). It seems that hospitalization was defined as a way to help ego. Thus, networks with close, intensive relationships with ego acted quickly to bring ego's perceived problem to medical attention and to hospitalize ego. Alternatively, in the studies by Lowenthal-Fiske (1964), McKinlay (1973) and Horwitz (1977), the seeking of medical services and hospitalization of ego was not as positively perceived accounting for the reported inverse relationship between network intensity and the speed of referral and hospitalization.
While a large portion of the study done by Sokolovsky and associates (1978) of former mental hospital patients residing in a Manhattan Single Room Occupancy (SRO) hotel was devoted to analyzing the structural differences between the networks of people exhibiting different degrees of schizophrenic symptomatology--and thus is not particularly relevant to the proposed study--it bears mentioning due to both the conclusions it reached on the relationship between social network characteristics and rehospitalization and its methodological approach.
The sample was small, consisting of only 41 SRO residents. However, as the geographic area was restricted to one hotel, a combination of participant observation and interviewing permitted greater data accuracy. Both chisquare tests and one-way analysis of variance were used for data analysis. It was shown that those residents who were not frequently re-admitted into psychiatric hospitals had a significantly higher number of multiplex relationships and their personal networks were significantly higher in density and size. Thus, network characteristics served a supportive role delaying or preventing reinstitutionalization. Furthermore, following previous lines of reasoning, it is probable that if those with supportive networks were eventually reinstitutionalized their presenting symptomatology would likely be much more severe.
Of particular methodological interest, was this study's nonutilization of friendship categories in the delineation of network fields. Rather, such fields as tenant-tenant and tenant-nontenant were used, with membership based upon contact criteria, with only links active within the prior year and with a contact frequency of once every three months included.
This approach was based on the premise that the concept of friendship is theoretically and empirically meaningless. Support for this position is demonstrated both in their study and in the future studies of Creecy and Wright (1979)
and Cohen and Rajkowski (1982), which reveal that normative second-order constructs of friendship may bear no relationship to the definitions in use by study respondents. Sokolovsky and his associates' 1978 study found self-proclaimed loners who, while denying friends, had large complex networks involving an assortment of material and instrumental exchanges. On the other extreme, Creecy and Wright found among their black rural native elderly a very nonrestrictive operating definition of friendship. In this sample it seemed that friendship was equated with friendliness, and thus required minimal social obligations. Finally, in another SRO-based study, Cohen and Rajkowski (1982) found that for their elderly population the label of friendship was not determinative of either the existence or absence of emotion and/or material exchanges.
Wentowski (1981) also explored the process of social exchange within the respondents' personal networks. Like Sokolovsky and his associates, a combination of participant observation and extensive interviewing was used for data collection. However, her sample was purposively chosen to be representative of the elderly population living in a community setting.
Fieldwork supported the function of social exchanges in role formation. Interestingly, Wentowski described how different exchange strategies are used to outline the degree
of interpersonal commitment desired in a relationship by the respective parties. While an "immediate" exchange strategy (usually instrumental, strictly balanced, and with an impersonal exchange medium) is conducive to maintaining social distance between people, a deferred strategy is "a form of balanced reciprocity which can be used to express a willingness to trust and to assume greater obligation" (Wentowski, 1981:604).
Wentowski's analysis emphasized the importance of balanced reciprocity in the maintenance of interpersonal relationships. Additionally, balance was recognized as an essential contributor to the self-esteem and pride of elderly people and also as "the major means of guaranteeing security in old age" (Wentowski, 1981:605). Along these latter lines, Wentowski identified the importance of building up "credit" through giving of oneself to others--either in terms of material or psychological resources. In this manner deferred obligations can be accumulated, thus giving the elderly a "right" to expect help from these others when and if they need it.
Although Wentowski did not specifically explore the function of reciprocity in the process of institutionalization, her analysis lends support to propositions contending that the existence of reciprocal relationships f acilitates delayed institutionalization (and hence when institutionalization occurs the presenting illness will be
more severe) and makes the possibility of deinstitutionalization more likely.
Both reciprocity and affection were the focus of
Horowitz and Shindelman's (1983) study of the variances in caregiving to the frail elderly in the home by the primary caregiver. Interviews with 203 New York City primary caregivers indicated that reciprocity and affection were the chief reasons for helping a frail older network member in need of care. Furthermore, both of these variables were positively correlated with the degree of caregiving extended by the primary caregiver. Affection was also negatively correlated to the level of perceived stress by that caregiver. However, this study was limited in that it only looked at the relationship with the primary caregiver and that it failed to control for any of the cultural or structural characteristics of the focal population.
Vaghn and Leff (1976) and Brown et al. (1972) also
examined the influence of social variables on the probability of mental hospital readmission. However, as they looked at the quality of expatients' family relationships rather than the structure of their networks, their focus was different than that of Sokolovsky et al. (1978). In both studies, Brown and colleagues' index of emotional response (a composite of the number of critical comments of someone else in the home, hostility, dissatisfaction, warmth, and
emotional overinvolvement) was found to be the best single predictor of patient symptomatic relapse (with the relationship in a negative direction), even when controlling for the patient's clinical condition at the time of admission. Although the index of emotional response is a qualitatively different variable than intensity, which is the focal interactional variable in the proposed study, their findings do alert one to the importance of both structural and interactional variables in the course of institutionalization and thus are worth noting.
In a study of much larger scope than those reviewed to this point, Wan and Weissert (1981) examined the relationship of social support networks (measured as numbers of relatives and friends in contact with the elderly person) to three dependent variables relevant to the process of institutionalization: (a) the health status of the impaired elderly; (b) the probability of being institutionalized; and
(c) length of stay in an institution. Data were obtained on 1,119 impaired elderly over a four-year period. Of special import was the fact that this group initially was not institutionalized. Thus, a comparison group of those who were not institutionalized during the course of the study was available.
Significant relationships were demonstrated between
social support networks and each of these variables. Those with a low number of sources for social support had
significantly worse physical and mental health at the end of the demonstration period than those with a high number of social support sources. The probability of being institutionalized was related to living alone vs. living with others; and length of stay in an institution was related to the impaired elderly having children, siblings, or grandchildren in their social support networks.
However, while the study was somewhat more sophisticated than those others mentioned to this point, due to its sample size and utilization of extensive multiple regression equations, the validity of its social support indicator is questionable. It is likely that all of the impaired elderly's relatives and friends are not providing them with useful and/or valued support services.
In a related veinr Wells and MacDonald (1981) examined the relationship of the elderly's network to the process of interinstitutional relocation. Longitudinal data were collected on 56 extended-care residents of one of Toronto's homes for the aged prior to and 8-12 weeks following nonvoluntary movement of the residents to a similar type of care facility. Network information was obtained on the number of "close" residents, staff, and family and nonresident friends that were in the residents' networks both before and after the move occurred. Not surprisingly, relocation had a disruptive effect on primary relationships,
with the mean number of primary ties identified by the residents dropping from 4.2 to 2.9, a change significant at p < .0001. However, this loss was mainly reflective of the loss of close relationships with the residents and staff from the former home. There was no significant change in their number of close family and nonresident friends.
Other examined consequences of relocation (declines in life satisfaction and psychological deterioration), while found to be significant, can be less readily attributable to the relocation process as the study failed to incorporate a control group in its design. The number of close nonresident friends and family, and staff relationships engaged in by the resident was associated with successful readjustment to relocation in terms of life satisfaction and physical and mental functioning. Hence, it seems that engagement in primary relationships functioned somewhat as a buffer of the examined negative relocation consequences.
The seminal study by Borup and associates (1978) on
interinstitutional geriatric relocation was not limited by the lack of a control group. An experimental design was used to study the effects of forced relocation on 529 of Utah's nursing home residents. The control group consisted of 19 randomly selected homes that were not undergoing relocation, yielding 453 respondents. Thus, the combined sample size was 982.
A breadth of consequences were studied, including the effects of forced relocation on the resident's life satisfaction, self-concept, sense of security, network, and health. Data were collected three to six months prior to the move and up to six months after relocation. Their conclusion was interesting and controversial.
The move itself is a stressful experience and
has emotional overtones for many patients.
However, that experience is not of such a
nature that it has negative effects beyond the experience itself. The findings of this study
overwhelmingly support the proposition that
relocation either has no effect or a positive effect with respect to the variables studied.
Furthermore, in a later article (1982), when Borup reexamined these effects in terms of the degree of environmental change experienced by the residents, even those residents experiencing the most radical environmental changes witnessed no significant negative consequences in any of these areas.
Of special interest in terms of this study was the
effect of relocation on the residents' networks. Unlike the conclusions of the Wells and MacDonald study (1981), Borup et al. (1978) found that relocation did not influence the number of residents who had friendship ties within the nursing home setting nor did it alter the resident's familial network system. It seems that the residents who were able to form friends at the old home tended to retain that ability after they moved. Thus, while the content of their
friendship network changed, size was stable. Significant declines in internal friendships did occur over this period in both control and experimental groups. However, as the intergroup differences were not significant, the declines are best attributed to the aging process, rather than relocation. Similar results occurred in terms of the other variables studied. When significant declines did occur in the relocated group, these declines were also experienced in the nonrelocated group, thus implying that relocation was not the precipitant.
Rundall and Evashwick (1982) also studied the relationship of network variables to the elderly's illness behavior. Sampled were 883 noninstitutionalized elderly. As in the work of Hammer (1963) and Perrucci and Targ (1982), health care utilization was conceptualized as a type of help seeking. In this case the focus was on such illness behaviors as length of time since one's last visit to a physician and the number of one's visits to a doctor in the past year. Of interest was the relationship of ego's level of satisfaction with his/her network to the use of professional services. Thus, the key independent variable was ego's perception of the condition of his/her network.
Information was collected on both relative and friendship networks, although the operationalization of friendship is unclear. Interestingly, while ego's satisfaction with
his/her friendship network was unrelated to utilization behavior, ego's perception of his/her relative network was significantly related to utilization behavior, even when controlling for perceived health status. Engagement, i.e., visiting one's relatives at least a few times a week and wanting to visit with them as much or more than one currently does, was positively related to the use of services and thus understood as a determinant of help-rendering activities. In contrast disengagement and abandonment were negatively related to the use of services and thus understood to indicate conditions where individuals were less likely to have networks that facilitated their health care utilization.
While Scheff (1966) did not specifically examine the
effect of social network variables on the process of institutionalizationr his research did test the related hypothesis that social contingencies external to ego are crucial determinants in the process of becoming mentally ill. In this regard, labeling, the acquisition of the role of mental illness, hospitalization, and discharge are all identified as consequences of such social factors as the power of the rule breaker, the social distance between him/her and the agents of social control, the tolerance of the community, and the availability in the culture of the community of alternative nondeviant roles.
Scheff'Is study (196 6) on the release plans for patients hospitalized in mental health facilities in a Midwestern state is an explicit test of this theory. A sample of 555 patients along with the hospital official legally responsible for patient care were surveyed for information regarding the patient's mental health state, social variables, and plans for the patient's release. Results supported his hypothesis. Controlling for the patient's degree of medical impairment, patient release plans were explained by (1) the type of hospital where the patient was located and (2) the length of the patient's confinement.
Allison-Cooke's (1982) review and analysis of the pattern of deinstitutionalization within Rhode Island's nursing home system also supports the effect of "external contingencies" on deinstitutionalization. In spite of an elaborate system operating to assess the appropriateness of medicaidsupported patient placement within the nursing home system and the feasibility of community relocation, in the course of a one-year period fewer than 1% of the patients at any level of care (skilled nursing facility, intermediate care 1, or intermediate care 2) were recommended for transfers to acute hospitals, to return home, or to move to some other type of care setting. This finding is particularly intriguing due to the fact that only 7.8% of the nearly 1,000 patients receiving intermediate care 2 were classified as displaying "an appreciable need" for institutionalized care.
Although Allison-Cooke's explanation for this is speculative, such contingencies as fear of potential relocation trauma; possible family resistance; assessment team limitations in the availability, assessibility, and knowledge of alternative services; and systemic fragmentation are proposed as possible explanations. once again, the theme of the importance of the resident or patient's network in the deinstitutionalization process is sounded.
Greenley (1972) also studied the relationship between
the timing of a patient's release from a state mental hospital and contingencies external to the patient's health status. His focus was on the impact a patient's family may have on his/her length of stay. Along this line, the key independent variable identified was the family's desire for the patient's release. Again, while this is not a network variable, as discussed in Chapter Three, the family's desire for the patient's release may be theorized to be a direct consequence of the network variables--density, reciprocity and intensity.
Longitudinal data were collected from 100 patients, their closest family member, and their psychiatrist via interviews, observation, and medical record review. Of the multiple measures of health status obtained, only the psychiatrist's judgments on the patient's level of psychiatric impairment and need for hospitalization were significantly
related to his/her length of hospitalization. Neither measures of dangerousness nor standardized symptomatology measures were significant length of stay predictors. Interestingly, the relationship between family desires and length of stay was stronger than that of any of the illness measures. Furthermore, when each of these measures was controlled for family, desires were still found to be significantly related to length of stay.
In conclusion, based on theory and previous research the following propositions were examined:
1. The density of ego's primary network is directly related to
a. the duration of his/her network ties;
b. the severity of ego's health status at the
time of ACLF entry;
c. the likelihood of ego's problem being
labeled by a professional;
d. the likelihood of ego's being referred to
an ACLF by a professional; and
e. the likelihood of ego's being relocated
from the ACLF to the home of ego or to the home of one of the members of ego's
2. The intensity of ego's primary network ties is directly related to
a. the duration of his/her network ties;
b. the severity of ego's health at the time of
C. the likelihood of ego's problem being labeled
by a professional; and
d. the likelihood of ego's being relocated
from the ACLF to the home of ego or to the
home of one of the members of ego's network.
3. The proportion of reciprocal ties in ego's network is directly related to
a. the duration of his/her network ties;
b. the severity of ego's health at the time
of ACLF entry;
c. the likelihood of ego's problem being
labeled by a professional; and
d. the likelihood of ego's being relocated
from the ACLF to the home of one of the
members of ego's primary network.
These propositions are also represented in the
following general equations* and illustrated in Figure 4-1:
1. Labeling by a Professional = Density + Intensity
+ Reciprocity + Sex + SES + Race.
2. Referral by a Professional = Density + Sex
+ SES + Race.
3. Severity of Health at Time 1 = Density + Intensity
+ Reciprocity + Sex + SES + Race.
*Each of these equations was also computed with degree data substituted for density data, perceived balance substituted for reciprocity, physical health substituted for mental health and both closest other and network intensity data. The focal networks included total primary, relative, and nonrelative networks.
4. Tie Duration = Density + Intensity + Reciprocity
+ Sex + SES + Race + Severity of Health
at Time 2.
5. Relocation to Home = Density + Intensity
+ Reciprocity + Sex + SES + Severity of
Health at Time 2 + Race.
Labeling by a
Severity of health Intensity,
____ ___ ___ ____ ___ ___ ___ density, and
Tie duration degree
Relocation to home
Referral by a professional (Density and
Figure 4-1. Hypothesized effects of network variables
on ACLF relocation
DATA AND METHODS
Sampling and ata Collectio
The study's sample consisted of those residents aged 60 and older who were new to ACLFs (less than two months residency). Sampling was limited to Orange and Seminole Counties, Florida. A longitudinal design was implemented, with phase one beginning in June and ending in September 1985 and phase two beginning in December and ending in March, 1986. Thus, there was a six-month lag between Time 1 and Time 2 data collection.
As the size of the ACLF was not a theoretically important variable in this study, the researcher arbitrarily decided to study only those residents of ACLFs whose total licensed capacity was less than or equal to 50 residents. This excluded seven institutions licensed for 65, 90F 95, 150, 188, 250, and 350 beds, respectively.
Forty-nine facilities met this restriction. Of these, two refused access to the researcher (a 15-bed and a 34-bed facility) and one allowed only limited access (a 34-bed facility). Of the remaining 46 facilities, 30 had at least one new resident during the intake phase of the study. All of these were visited, resulting in a total sample size at Time 1 of 85 residents.
Of interest were both the resident (otherwise referred to as ego) and the resident's primary or ego-centered networks. To this end, Time 1 data were collected via personal interviews with new residents ACLF caregivers, and ego's closest available other (otherwise referred to as alter). The reasons for this strategy were multiple. First, as discussed in Streib (1983), it was anticipated that many residents would not have sufficient cognitive ability to respond accurately to the questionnaire. Thus, it was necessary to plan systematically for an alternative survey respondent. Ego's "closest" available other was felt to be the most accurate substitute.
To analyze the appropriateness of this substitution, matching data from alter was sought for each resident at Time 1, allowing paired t-tests to be done to determine any differences between obtained ego and alter responses. If ego was cognitively able, he/she identified alter and gave the researcher permission to contact alter and information on how to do so. If ego was unable to supply this informationt it was obtained from his/her caregiver.
The second reason for using multiple informants was due to the predicted involvement of ego's network in his/her relocation. Information of this process from the network's perspective was, thus, also theoretically valuable. And, finally, data from the caregivers were obtained in regard to
ego's current self-care abilities as they were assumed to be the most knowledgeable and objective sources of this information.
While it was recognized that the "key informant approach" to information about ego's network would undoubtedly "slant the truth" in the direction of ego's (or ego's closest other's) perceptions, it was not economically feasible to interview all of the identified members of ego's primary network. Furthermore, it is a common and valid research alternative to utilize informants for this information when it is not feasible for the subject to be observed or questioned directly (Dean and Whyte, 1969). Additionally, as Becker so aptly argues, "The question is not whether we should take sides, since we inevitably will, but rather whose side we are on. . We must always look at the matter from someone's point of view" (1970:15,22).
Thus, network data obtained in this manner could not help but be biased from the informant's perspective. Yet, the reliability and validity of this method of data collection was maximized by (1) quashing ulterior motives of the informants (2) reducing bars to spontaneity, and (3) cross checking the account of an informant with the account of other informants. Ulterior motives were quashed by explaining to the informants that the researcher was in no position to alter the existing situation. Bars to spontaneity were lifted by assuring the informants of
confidentiality and conducting interviews in a private setting. Andr cross checking was done when ego was the primary informant by also interviewing ego's closest network member about information regarding ego's primary zone and the process by which ego was relocated to an ACLF.
This combined strategy was successful in that only four of the initial sample were dropped from the study at phase one, resulting in a completion rate of 95.2%. Thus, most of Streib's (1983:42) "excluded 20%" were included in this study. Nonresponses were due to the combined circumstances of mental incompetence of the resident and participation refusal of ego's closest available other. An assessment of ego's self-care abilities was obtained from caregivers for all of the respondents. Thus, 81 surveys were completed by either the resident or his/her closest other yielding a total sample size at Time 1 of 81.
Of this remaining sample, six surveys were not cross checked due to alter nonaccessability. Access was either denied by the respondent (2), or by alter (2), or it was limited due to the unavailability of a local significant other (2). Thus, 75 alters were interviewed during the intake phase of the study. All but five of these were faceto-face interviews. Phone interviews were conducted due to preference of the significant other (4) or distance of alter from Orange County (1).
Twenty-eight residents (34%) were not able to complete the survey at Time 1 due to mental incompetence (26) or physical infirmities (2). Ego's mental capacity was assessed at the onset of the interview (after obtaining informed consent) via a modified version of Pfeiffer's Short Portable Mental Status Questionnaire (1975). The tool was situationally adapted to the ACLF population by substituting Pfeiffer's questions "What is your telephone number?" and its alternative for those without a telephone, "What is your street address?" with the question, "In which room do you live?"
The Short Portable Mental Status Questionnaire has been specifically designed as a gross test of intellectual functioning for use on the elderly population. In addition to its suitability for the population of the proposed study other key advantages include its brevity and ease of portability (see Appendix B). Only ten questions are asked of each subject. Five primary aspects of mental functioning are addressed: short-term memory, long-term memory, orientation to surroundings, information about current events, and the capacity to perform serial mathematical tasks. Field testing was done by Pfeiffer (1975) with a population of 926 subjects. As his analysis suggested that both education and race influenced performance, they are adjusted for in score evaluation. Scores are then coded into four distinct levels of intellectual functioning: intact
intellectual functioning (0), mild (or borderline) intellectual impairment (1), moderate (or definite) impairment
(2), and severe impairment (3).
Pfeiffer's interpretation of these levels was useful in determining the respondent's ability to respond accurately to the research questionnaire. If ego's intellectual ability was measured to be intact or only mildly impaired, ego was considered the primary survey informant and the interview was continued. However, if ego's mental functioning was measured as either moderately or severely impaired, the interview was terminated and the person closest to egor as identified by staff and/or ego, who was accessible for interviewing was contacted and considered to be the primary informant for these data.
Personal interviews with ego and alter at Time 1 set
the stage for follow-up data collection at Time 2. Initial interviews were conducted in a leisurely nonthreatening manner in to facilitate rapport and the establishment of trust with the respondent. Generally, alter was interviewed in his/her home, with occasional contacts occurring over alter's lunch hour. Frequently the researcher reframed her role by bringing her infant along. Given the nature of the population (both ego and alter were both generally elderly women), this novel approach was an effective "ice breaker."
These strategies both maximized data quality at Time 1 and minimized the respondent drop out rate at Time 2. Although six of the respondents were lost to the study at Time 2 due to their deaths, only one was lost due to respondent refusal at Time 2. This refusal was not surprising, because it came from a closest other" who had also refused to participate in the study at Time 1. While ego's responses were available at Time 1 (and hence substituted for alter's) ego had moved into an unidentified nursing home at Time 2 and hence was not contactable by the researcher. Additionally, only partial follow-up network information was available on three residents who had moved out of the area, due to alter's lack of knowledge of this information.
An alternative strategy was used for data collection at Time 2. While a follow-up contact with ego was attempted for all of the original respondents alter was only recontacted if ego's mental or physical status prevented valid survey completion (n = 26), if ego had moved to an out-oftown location (n = 3), or if the family preferred that the researcher contact them rather then ego (n = 2). The rationale for this diminutive approach was that ego and ego's current caregiver were the persons closest to and hence most valid sources of the data sought at Time 2. (The focus at Time 2 was on ego's health perception of person-environment fit, and network ties.) And, as the closeness of fit by substitute alter responses had already been determined by
matching ego and alter responses at Time 1 this did not need to be repeated at Time 2.
With one exception (this person was hard of hearing,
and could better understand the researcher when visual contact was present), alter contacts at Time 2 were via telephone interview, rather than face-to-face contact. Phone interviews were the method of choice for this phase, as it was determined that such potential compromises to data quality as increased refusal rates and greater interviewer respondent social distance would be slight, due to the care taken at time one to establish a comfortable relationship with the respondent, and the economic savings would be significant (Frey, 1983). Furthermore, phone interviews were more convenient for ego's closest other as well, demanding less time and effort on their parts. Hence, the interviews were more likely to be favorably received.
Network delimitation attempted to define ego's inner
circle of contacts--those people with whom ego was actively tied emotionally and/or via material exchanges. Wellman's (1981) relational criteria of contact frequency, tie content, and tie intimacy were the critical elements used for boundary definition. Both relative and nonrelative fields were delineated to allow for analysis of both ego's total primary network and key primary network subfields. This
strategy was followed in lieu of Cubbitt's (1973) observation that general network characteristics may mask significant different characteristics in sections of the network.
Data were obtained via a two-phased approach. Respondents were first asked to identify two groups of people that ego had been in contact with on a regular basis during the past year. The first group was to consist of relatives, and the second included nonrelative adults (excluding residents at the ACLF) that ego felt close to.
Ego and alter were then asked a series of questions
about each of these people to determine how frequently they were in contact, how emotionally bonded ego was to them, and how many material links they shared. Ego was considered the primary informant for all network datar as alter was not as likely to know of all of ego's close contacts, and alter's responses were substituted as necessary. If minimal inclusionary criteria were not met for any identified person, he/she was then excluded from ego's inner circle of contacts. In this manner, ego and alter's perceptions were "fine tuned" resulting in a more standardized delimitation of ego's inner circle. Interestingly, only twelve respondent-identified others did not meet these criteria, and thus were dropped from ego's inner circle.
In terms of contact frequency, ego needed to be in contact with an identified other at least several times
during the past year to be considered a member of ego's inner circle. "Several times" was defined as existing between once a year and every other month on a continuum from no contact to daily contact. To account for the mobility of our urban society (Adams, 1967) and the probable neighborhood boundedness of many of the resident's peer friends and family (Cantor, 1979), a contact was not restricted to visiting. Rather, a contact was considered to be made if the resident received a phone call, a letter, or a visit from alter.
Emotional Bondedness is a construct comprised of three components: (a) The sense that one receives emotional support from another, (b) the sense of mutual sharing with another, and (c) feelings of positive affect with another. Constuct operationalization was accomplished via Snow and Crapo's Emotional Bondedness Scale (1982). This gave the researcher a method of quantifying the degree of social distance between ego and a network member, thus operationalizing the der of friendship in a relationship and the dgree of closeness in relative links. The scale is a 12item cumulative ordinal scale with scores varying from 1-3 for each item. Thus, the total bondedness score can range from 12-36 (see Appendix A).
To meet minimal inclusionary criteria, a bond score of at least 24 (indicating ego and alter were at least "somewhat" bonded) was necessary or at least one material link
needed to be identified. Material links were defined in terms of the existence of any one of three types of assistance: personal assistance, money or loans, or other gifts. As links can flow both to and from ego, data on both instrumental and dependent links were obtained, yielding a potential range of 0-3 material links between ego and a network member.
Measurement of Dependent Variablea
Five dependent variables were identified: (1) the
duration of ego's network ties, (2) the source of the label
of ego's problem, (3) the severity of ego's health status at the time of ACLF entry, (4) the source of ego's referral to an ACLF, and (5) the likelihood of ego's being relocated from the ACLF to his/her home or the home of a network member.
The duration of ego's social ties was measured with
longitudinal data. As mentioned earlier, there was a sixmonth lag between initial and follow-up phases of the study. While it was recognized that this relatively short interval may not be a sufficient time period to assess the duration of ego's social ties, it was believed that at this point some trends in the data would be detected. Furthermore, as it is generally recognized that this population is rela-
timely unstable, it was determined that a short lag period would facilitate follow-up data collection and might help minimize study dropouts.
Changes in mean network frequency of contact and the mean number of material links between ego and each of his/her primary network members from Time 1 and Time 2 as reported by ego (with alter substitutions as necessary) were the indicators of this variable. Data on contact frequency (visiting, speaking, and exchanging letters) at Time 1 were obtained by asking the respondent three questions: "On average, about how often have you (ego) seen, spoken to or exchanged letters with (insert name of each identified network member) during the past year?" Eight different categories emerged for each type of contact (visiting, speaking, and writing) pattern at Time 1: not in the last year (0), one time a year (1), several times a year (2), every other month (3). monthly (4), every other week (5), weekly (6). several times a week (7), and daily (8).
At Time 2 a similar question was used. As only a sixmonth time period was assessed, it was necessary to categorize the data slightly differently. The first three categories were contracted into two: Not at all (1) and once or twice (2)--with the others unchanged. A mean total network contact score and subnetwork contact scores were obtained for Time 1 and Time 2 data by summing ego's contact scores with each network member and then dividing by network size.
Measurement of tie duration with data on material links was accomplished by determining the presence or absence of three different types of material links (personal assistance, gifts, and financial assistance) from ego to each network member and then from each network member to ego. Links could, thus, be reciprocated, dependent, or instrumental. A range of zero to three links was possible per tie. The mean number of network links was obtained by summing the material links between ego and each network member and then dividing by network size. Once again, this was computed for both ego's total network and network subfields.
Dependent variables 2, 3, and 4 all refer to the process by which ego's relocation was orchestrated. Data on this process were gathered via open-ended and closed questions. Open-ended questioning was used at the beginning of the interview to "allow ego and alter to talk.n The reasons for this approach were multiple. First, it was felt that given the potential stressfulness of ego's move, allowing the respondent to ventilate his/her feelings would be therapeutic. Hence, this was a way of reciprocating the respondent's contribution to the researcher's study. Secondly, by making time to listen to the respondents' concerns the researcher was able to demonstrate interest in them as people, not simply as potential sources of data. This
facilitated rapport and a sense of trust. Third, as little was known about this process, leaving some of the questions open-ended allowed for a potentially greater generation of new knowledge.
Close-ended questions were then used to determine answers for questions with a few, discrete responses. Thus, information on such questions as (1) Who had first labeled ego's condition as "out of place" in his/her current living situation, (2) who had suggested relocating ego into an ACLF, and (3) what was ego's current level of self-care abilities was obtained in this manner.
As noted earlier, both ego's and alter's perceptions of the process of ACLF entry were of interest. Yet, it was recognized that as ego's network was probably the primary coordinator of the move, alter's responses would generally be closest to "the truth." Thus, data on each of these variables were tabulated in three ways: using ego responses only, using alter responses only, and with alter as the primary informant, using ego substitutes as necessary. When both ego and alter responses were available, a chi-square analysis was done to test for significant between-source differences. Additionally, ego's primary caregiver was the source of data on ego's current self-care abilities.
In terms of ACLF relocation, ego's "problem" was basically one of increased dependence. Essentially, ego's con-
edition came to be perceived as one that no longer "comfortably fit" in his/her current environment. The key variable identified here was the primary source of this label. This was determined by asking the respondent, "Who first suggested that you (ego) might have to move into another living situation?" Five rather specific responses were possible: "a relative" (0), "a personal contact" (1), "Your doctor" Mr "you determined it yourself" (3), and Another health professional" (4). These were then aggregated into formal (2 and 4) and informal (0, 1, and 3) categories, as in the work of Horwitz (1977).
While the perception of a change in ego's condition may be understood as a trigger for action, it was understood that ego's actual health status at this point was likely to be highly variable. Ego's "environmental fit" is largely the result of the willingness or ability of ego's network to accommodate to his/her needs. Thus, it was postulated that the objective severity of ego's health would vary given key conditions in ego's network.
Measurement of health status can be determined based
upon three different basic approaches: (1) the utilization of clinical records, (2) clinical examinations, and (3) household interviews. Due to ACLF regulations, the present population is required to have a medical record on file at their place of residence. Furthermore, it is mandated that this file is to include a record of a recent medical
examination (between 60 days prior to admission and 30 days after admission) of the resident. However, unless the examination is performed after admission (and in this case must be reported on a standardized form), the examination records will provide variable degrees of information on the resident's health. Furthermore, even when the examination form is standardized the comparability of the medical evaluations is questionable due to observer variation, as no one physician or nurse practitioner has been designated to perform all of the post ACLF examinations. Thus, this source of morbidity data was not considered as an indicator of the resident's health status.
Three other indicators were utilized: a mental health measure which was derived from the mental functioning screening done at the onset of the resident interview, a self-assessment of health measure as determined from interviews with ego and alter, and a self-care index which was derived from Katz's Activities of Daily Living (ADL) Questionnaire (Katz, Ford, Moskowitz, Jackson, and Jaffe, 1963). This information was obtained from ego's primary care giver. As the Short Portable Mental Status Questionnaire has already been described, only the latter indicators will now be discussed.
Self-assessments of ego's health were addressed to the time of ego's move into the ACLF. Four responses were
possible: very good (0), good (1), fair (2), and poor (3). As self-assessments tend to be influenced by salient reference groups (Ferraro, 1980; Fillenbaum, 1979), it was anticipated that controls for age and sex would be necessary to relate this measure to the more objective health indicators of mental capacity and self-care.
The Katz scale (see Appendix C) is a cumulative ordinal scale that measures a person's level of functioning in six activities which people perform habitually and universally (bathing, dressing, toileting, transferring, continencer and feeding). Grading of the scale is as follows (Katz et al. 1963:915):
A. independent in feeding, continence,
transferring, going to toilet, dressing,
B. independent in all but one of these
C. independent in all but bathing and one
D. independent in all but bathing, dressing,
and one additional function;
E. independent in all but bathing, dressing,
going to toilet, and one additional function;
F. independent in all but bathing, dressing,
going to toilet, transferring, and one
G. dependent in all six functions; and
Other. dependent in at least two functions,
but not classifiable as C. D, E, or F.
Interestingly, Katz points out that while this order of
functional ability was determined through the evaluation of over 2,000 elderly the pattern parallels "the recognized developmental pattern of child growth as well as the behavior of members of primitive societies" (1963:917). Furthermore, as observed in the Katz study, the process of rehabilitation and recovery of function is also consistent with the outlined ADL Scale. "Recovering patients passed through three stages: an early recovery of independence in feeding and continencer subsequent recovery of transfer and going to toilet, and, lastly, often after discharge, the recovery of complete independence in bathing and dressing" (1963:917). Of special interest is the observation by Katz and his associates that health is a process. Health is dynamic, not static. Thus, the researcher expected to observe some changes in the level of assessed health from Time 1 to Time 2 of data collection.
Once ego's condition was perceived as a "problem," a response was in order. This is the third identified stage of the relocation process. In this study, the response was to relocate ego into an ACLF. The key variable here is who was responsible for referring ego to this living alternative. This was measured by asking, "Who first suggested that moving into an ACLF might be a good idea?" Responses were identical to those for the labeling variable: "a relative" (0), "a personal contact" (1), "Your doctor" (2), "you determined it yourself" (3), and another health
professional" (4). Responses were then aggregated into formal (2 and 4) and informal (0, 1. and 3) categories.
The fifth dependent variable, the likelihood of being relocated from an ACLF to a home environment, was measured as a dichotomous variable with the location of ego at Time 2 used to determine whether or not relocation out of the ACLF to a home environment had occurred. While this information was generally determined by the researcher after visiting ego, six of those residents who had left the ACLF were not able to be contacted. For these, either the former ACLF caregiver or the closest other was substituted as the information source. Ten responses were possible: living alone without any help (0), living alone with the help of family and friends Mr living alone with the help of formal agencies (2), living alone with the help of family, friends, and formal agencies (3), living with family/friends (4), living with family/friends and being helped by formal agencies (5), living ig home (6)r located in a hospital, but planning to return to an ACLF (7), located in a hospital and planning to return home (8)r living in same ACLF (9), and living in different ACLF (10) were aggregated into the dichotomous variable: returned to home environment (0, lf 2, 3, 4, 5, and 8), or remained in an institutional setting (6, 7, 9, and 10).
Measurement of Independent Variables
Three primary independent variables were identified:
(1) the connectedness of ego's primary ties, (2) the direction of ego's primary ties, and (3) the intensity of ego's primary ties. As these are all network variables, ego was considered the primary informant, with alter substitutes used as necessary.
Two different measures of network connectedness were computed--density and degree. once again, measures were computed for both ego's personal network (defined as those family plus nonresident alters meeting minimal inclusion criteria) and for kin and nonresident subfields.
As was outlined in the theoretical chapter of this
dissertation, density is the proportion of the theoretically possible direct links that exist in a particular network (Barnes, 1969). Mathematically this measure was formulated as
D= 100 x Na
1/2 N (N 1)
where D refers to density, Na refers to the number of actual relations in a network, N refers to the number of persons involved, and 1/2 N x (N 1) refers to the number of theoretically possible relations in a particular network (Neimeijer, 1973:46).
Degree is the average number of relations members of a network have with other members. This is operationalized by
the following mathematical formula: d = 2 x N
where Na refers to the number of actual relations and N refers to the number of persons involved (Neimeijer, 1973:47).
Measuring the degree of a network is especially useful when one is comparing the connectivity of networks of disparate sizes as it takes into account the size dimension of ego's network. And, while a large network size variance such as that which was discussed by Cubitt (1973) was not anticipated in this population, it was not known if a theoretically significant size difference would be present. Thus, analyzing the effects of both of these variables on ACLF placement gave a more complete picture of the relationship between network connectivity and this process.
It was anticipated that some residents would either be without any personal network or have such small networks that their total network size and/or their subnetwork size would have less than two members in addition to themselves. As density as well as degree measures are only meaningful if network size is greater than or equal to three, measurement of these variables for these subjects is not possible. However, examination of this "network deficient" group is of interest in and of itself. Thus a demographic and health
profile of those with deficient total, relative, and nonrelative network was included in the analysis, as was a comparison of how this group "looks" and how they orchestrated their move into the ACLF in comparison to the nondeficient group.
In adhering to this strategy, the interrelatedness
between density and degree was not neglected. As outlined by Neimeijer (1973), density can be substituted into the formula for measuring density:
where D refers to density, d refers to degree, and N refers to the number of persons in the network being analyzed (1973:48). As can be seen, density varies directly with degree, but inversely with network size. Thus, the effects of these variables on the dependent variables were analyzed separately, minimizing the problems of multicollinearity.
Data on the number of actual links (Na) were obtained by listing each member of ego's primary network on a blank sheet of paper. The researcher then assisted the respondent in connecting each of these members who were currently in regular contact with each other. In this case network size
(N) and the number of actual links (Na) included all network members and linkages identified by either ego or alter (see Appendix D, Number 17).
The second identified independent variable was tie
directedness. Of interest was the variable interactional effect of unidirectional verses reciprocated links. As was pointed out in the theory chapter of this dissertation, the notion of tie reciprocity is broader than that of tie symmetry, implying equivalency in social exchanges rather than indicating that the exchanges be roughly identical. Thus, a tie was considered reciprocated if there was a link flowing from ego for each link flowing to ego. In this regard, the existence of material links (i.e., personal assistance, money or loans, or other gifts) to and/or from ego was assessed. "Objective" network reciprocity scores were then determined as per Sokolovsky et al. (1978) by computing the proportion of ego's total links that were reciprocated. Consistent with the previously outlined methodology, both subfield and total personal field scores were computed.
Along these same lines it is also important to recall that the perception of tie equivalency by the involved parties is also cited. Thus, consistent with the approach used by Ward, Sherman, and LaGory (1984), this "objective" measure was complimented by questioning the respondent, "When you consider everything that you share with (substitute name of network member) i.e., personal assistance, gifts, financial assistance and love and companionship, would you consider that over the long run you get about as
much from ()as you give to ( )?" Subjective network
reciprocity measures were then determined by computing the proportion of ego's total relationships that were perceived to be reciprocated. Once again, both subfield and total personal field scores were computed.
The third identified independent variable in this study is tie intensity. While a theoretical understanding of intensity has been demonstrated in the literature (Epstein, 1961; Granovetter, 1973; Mitchell, 1969; Wheeldon, 1969)f validated empirical indicators of this concept are somewhat elusive (Marsden and Campbell, 1984). As intensity is a multidimensioned construct involving components of time spent (frequency of contact and duration), depth (emotional intensity and intimacy), and reciprocity as Granovetter theorized (1973) and Marsden and Campbell (1984) attempted to empirically verify, its measurement should take into account each of these dimensions. This was the strategy used by the researcher for measuring the intensity of the link between ego and his/her "closest other." An attempt was made to maximize the "fit" between theory and reality, by operationalizing each of its dimensions. Intensity was determined to be indicated by
1. the degree of emotional bondedness between
ego and alter (as perceived by ego);
2. the degree of emotional bondedness between
ego and alter (as perceived by alter);
3. the duration of the relationship;