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Primary social network : predictors and consequences of entering an adult congregate living facility

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Title:
Primary social network : predictors and consequences of entering an adult congregate living facility
Creator:
Bear, Mary J., 1955-
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English
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ix, 347 leaves : ill. ; 28 cm.

Subjects

Subjects / Keywords:
Caregivers ( jstor )
Friendship ( jstor )
Health status ( jstor )
Homes ( jstor )
Mathematical variables ( jstor )
Mental health ( jstor )
Nursing homes ( jstor )
Older adults ( jstor )
Radiocarbon ( jstor )
Social networking ( jstor )
Aged -- Family relationships -- Florida -- Seminole County ( lcsh )
Congregate housing ( lcsh )
Dissertations, Academic -- Sociology -- UF
Sociology thesis Ph. D
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bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1986.
Bibliography:
Bibliography: leaves 335-346.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Mary J. Bear.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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030172437 ( ALEPH )
15911047 ( OCLC )

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PRIMARY SOCIAL NETWORK:
PREDICTORS AND CONSEQUENCES OF
ENTERING AN ADULT CONGREGATE LIVING FACILITY









By

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



















































Copyright 1986

by

Mary J. Bear















ACKNOWLEDGMENTS


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

CHAPTER

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




iv











CHAPTER

six THE PARTICIPANTS: THE NEW
RESIDENTS . . . . . . . . 97

Presenting Demographic and
Health Profi .... .. .. 97
Morphological Network
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
Referral 153
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
Interactional Network
Characteristics . .* . . . 183



v











CHAPTER Paqe

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

APPENDIX

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



vi











APPENDIX

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



































vii














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

December 1986

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.








ix















CHAPTER ONE
INTRODUCTION


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


1








2



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








3


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








4


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








5

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








6


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.








7


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.


Theoretical Gaps

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








8


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.








9

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








10


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
problematic?

--How did the ACLF resident become informed of
ACLFs?

--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
entry process?

--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








11



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.















CHAPTER TWO
NETWORK ANALYSIS


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


12








13


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








14


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








15


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








16


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.


Morpholocical Concepts

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








17


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








18



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).


Interact.ional-Concepts

In contrast to morphology, which describes network

attributes, interactional network characteristics delineate linkage attributes. Included in this category of analysis








19



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








20


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








21



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








22


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








23



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








24



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








25


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








26



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.















CHAPTER THREE
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.


27








28



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;








29


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.








30



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








31


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.








32


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








33



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








34



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.








35


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.


Tie Duration

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








36


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








37



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








38



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








39


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.














CHAPTER FOUR
LITERATURE REVIEW:
NETWORK VARIABLES
AND INSTITUTIONALIZATION


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.



40








41


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.








42



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








43


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.








44


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.








45



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








46


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.








47


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.








48


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,








49



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
mild conditions.

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.








50


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








51



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.








52


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)








53



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








54


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








55



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








56


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








57



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,








58


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.








59


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.
(1973:172)

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








60



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








61


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.








62


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.








63


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








64


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
primary network.

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
ACLF entry;

C. the likelihood of ego's problem being labeled
by a professional; and








65



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.








66


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.








67





Labeling by a
professional



Severity of health Intensity,

reciprocity,
____ ___ ___ ____ ___ ___ ___ density, and
Tie duration degree



Relocation to home




Referral by a professional (Density and
degree




Figure 4-1. Hypothesized effects of network variables
on ACLF relocation















CHAPTER FIVE
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.


68








69



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








70


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








71



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).








72


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








73



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."








74


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








75



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

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








76



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








77


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








78



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-








79


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.








80



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








81



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-








82


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








83



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








84


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,
and bathing;

B. independent in all but one of these
functions;

C. independent in all but bathing and one
additional function;

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
additional function;

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








85


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








86



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).








87


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








88



the following mathematical formula: d = 2 x N
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








89


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:


D =10x
(N 1)

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).








90



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








91


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;




Full Text
176
evicted from her home and was waiting for an opening in an
elderly housing project.
The "conditionally legitimate" label also frequently
surfaced in the interviews with those who returned to the
home of a relative. In this case ego's temporary "out of
place" label was often due to the ill health of the relative
who had been caring for ego. Ego's ACLF entry acted as a
respite for the ailing relative facilitating his/her recov
ery which readjusted the home environment allowing ego to
again fit in adequately. This is aptly expressed by the
respondents themselves.
When my sister's health improved she wanted
me back. Neither of us [ego and her sister]
felt good about the place. We don't like to
be dependent. This is the way we want it.
(a former resident)
[Ego's] doing beautifully now, and so is his
sister. When her health improved she wanted [ego]
to go back. They kind of worked out their problems.
He's more appreciative of his sister now. (a niece)
All of those who moved to a nursing home did so due to
a decline in their health status. Although this move was
made reluctantly, it often resulted in giving alter more
freedom. In contrast to the ACLF, the nursing home has
medical care readily available, thus relieving alter from
having to take ego to doctor appointments, or to make any
necessary decisions about the medical management of ego's
care. This is well explained by the daughter of one former
ACLF resident.


95
intensity relationship. In terms of reciprocity, if all the
three possible links were reciprocated this was scored high.
If one or two links were reciprocated this was scored
medium, and if no links were reciprocated this was scored
low.
In terms of ego's network, network emotional bonded
ness, a partial component of intensity, was used as the
variable indicator. Measurement was accomplished by asking
the respondent the 12 items in Snow and Crapo's (1982) scale
in regards to ego's relationship with each network member.
Responses were then totaled for both ego's subnetworks and
total primary network and divided by network size to obtain
a mean. This strategy was chosen due to the complexity of
obtaining a composite network measure for each of these
subcomponents and the demonstrated superiority of the mea
sure of the emotional intensity of a tie over any other
single indicator available to us (Marsden and Campbell,
1984) .
Controls were added for sex, race, and socioeconomic
status as they have been both theorized and demonstrated to
have an effect on health-related behavior (Freidson 1970;
Gove and Howell, 1974; Horwitz, 1977; Verbrugge, 1985).
Each of these was dichotomously coded with males, whites,
and private payers coded 0 and females, nonwhites, and
private residents coded 1.


213
In terms of the control variables, while remaining in
an institutionalized setting did tend to be negatively re
lated to ego's contact with network members at Time 2, the
relationship was not consistently significant across type of
contact and the different focal networks. Remaining in an
institutionalized setting was negatively related to visiting
contact by ego's total network, regardless of whether one
controls for ego's self-care ability at Time 2 (p < .01) or
ego's mental health (p < .05). However, the relationship
with location at follow-up and the mean frequency of ego's
total primary network speaking contact was only demonstrated
when controlling for ego's self care ability (p < .05).
This relationship was no longer evident when ego's mental
health was controlled for. Given that unlike physical
health at Time 2, ego's mental health is a significant
predictor of total network speaking frequency, the relation
ship with speaking and location may be spurious.
In terms of relative visiting and speaking contact
after ACLF entry, those that had remained in an institu
tionalized setting were visited and spoken with by relatives
on average just as often as those who returned home, regard
less of the controlling health variable included in the
analysis. For nonrelatives, location was only useful in
explaining speaking at Time 2. Those remaining in the ACLF
were in less speaking contact with nonrelatives than those
who returned home (p < .05).


80
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 assis
tance, 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 instru
mental. 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 sub
fields.
Dependent variables 2, 3, and 4 all refer to the pro
cess by which ego's relocation was orchestrated. Data on
this process were gathered via open-ended and closed ques
tions. Open-ended questioning was used at the beginning of
the interview to "allow ego and alter to talk." 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 thera
peutic. Hence, this was a way of reciprocating the respon
dent'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 peo
ple, not simply as potential sources of data. This


214
Thus, those that remain in the ACLF are not in that
much less contact with their network than those who return
home. This is surprising, and at least at first glance,
encouraging. However, as the t-test findings discussed in
Chapter Eleven revealed that only relative visiting does not
decline significantly after ACLF, entry one cannot conclude
that moving into an ACLF does not negatively affect contact
frequency.
Rather, the probable explanation for these findings can
be found from the regression on returning home. Those who
return home tend to come from networks to which they are
less intensely bonded. Finding that respondents who return
home are so infrequently in visiting and speaking contact
with their primary network members upon their return home
that they often have no more network contacts than those who
have remained in an institutionalized setting, then, is
another indicator of the low degree of interactional network
supportedness experienced by those respondents that returned
home.
In terms of the other control variables, the delineated
pattern of network contact at follow-up was different than
the network contact pattern with ego prior to ACLF entry for
race, sex and mental health. Only socioeconomic status and
physical health retained the same effect on network contact
after ACLF entry (see Appendix I and Appendix K, Table K-2).


168
Table 9-2 Frequency comparisons of labeling sources by
deficient and nondeficient network groups
Network Group
Labeling Deficient Nondeficient Deficient Nondeficient
Source
Total
Total
Relative
Relative
Formal
4
22
5
21
Informal
0
55
2
53
Total
4
77
7
74
Fisher 1s
Exact
Test
8.79**
5.37*
*p < .05
**p < .01


22
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 sim
ply, 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 multi-
plexity is correlated with the strength of an interpersonal
relationship. As presented by Kapferer (1969:213), "Multi
plex 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 multi-
plexity 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


292
18. Now I want to move on to some questions about ego's
family and friends. The last time we visited, you
identified two groups of adults that ego had been in
contact with on a fairly regular basis the year before
ego moved into the ACLF. The first group consisted of
relatives and the second was all the adults ego felt
close to (excluding relatives and other residents
at the ACLF).
I have those names in front of me. Now, for each
person you identified, I am going to ask you a series
of general questions about ego's relationship with
him/her over the past six months. [List network in
charts in back of questionnaire. Record answers to
(18) in same chart.]
18a. Name to be inserted by interviewer.
18b. Relationship to be inserted by interviewer.
18c. On average,in the past six months, how often has ego
seen ( )?
(1)
Not at all
(2)
Once
(3)
Every other month
(4)
Every month
(5)
Every other week
(6)
Once a week
(7)
Several times a week
(8)
Daily
18d. On average, in the past six months, about how often
has ego talked with ( )? (Code as above.)
18e. On average, in the past six months, about how often
has ego exchanged letters with ( )? (Code as above.)
18f. In the past six months, has ( ) given ego any
financial assistance?
(0) No
(1) Yes
18g. In the past six months, has ( ) given ego any
personal assistance?
(0) No
(1) Yes


56
emotional overinvolvement) was found to be the best single
predictor of patient symptomatic relapse (with the relation
ship in a negative direction), even when controlling for the
patient's clinical condition at the time of admission. Al
though the index of emotional response is a qualitatively
different variable than intensity, which is the focal inter
actional variable in the proposed study, their findings do
alert one to the importance of both structural and inter
actional 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 relation
ship 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 insti
tutionalization: (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 insti
tutionalized. Thus, a comparison group of those who were
not instititutionalized 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


232
Time 1 contact
at Time 1
Figure 11-2. Variable effects on tie duration
Note: Closest other intensity, network bondedness, degree,
marital status, and sex are omitted as they were not
significant at p < .05.


44
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 instu-
tionalization.
In a more limited study, Smyer (1980) also analyzed
some key variables that discriminate between institutional
ization 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.


Table 11-2--.
Variable Name
Total Network
(N = 62)
Relative Network
(N = 60)
Visiting
Speaking
Visiting
Speaking
B
SD
B
SD
B
SD
B
SD
Mental Health,
Time 1
-.14
.12
-.28**
.14
.03
.13
-.19*
.11
Location, Time
2
-.31**
.53
-.26
.61
-.02
.62
.08
.55
2
R
.40
.24
.41
.27
*p < .10.
**p < .05.
***p < .01.
* * *p <
0001
209


169
Table 9-3. Frequency comparisons of referral sources by
deficient and nondeficient network groups
Network Group
Referral
Source
Deficient
Total
Nondeficient
Total
Deficient
Relative
Nondeficient
Relative
Formal
4
23
4
23
Informal
0
54
3
51
Total
4
77
7
74
Fisher's
Exact
Test
8.
31*
1
.93
*p < .05


136
long-term care facility by professionals or personal net
work members.
The relative importance of professionals, particularly
physicians, in the labeling and referral process is secon
dary to that of ego's informal network. This finding is
consistent with that reported by Tobin and Lieberman (1976),
Habenstein, Keifer, and Wang (1976), and by Florida's Office
of Management and Evaluation Review (1985). Given physi
cians' traditional focus on the physiological variables
influencing one's health, it is not too surprising that they
tend to overlook the environmental variables influencing the
health of their clients. It seems that even when a physi
cian did identify ego's situation as a problem, ACLF refer
ral was just as likely to be made by another source as by
the physician. In fact, only 8.6% of the respondents iden
tified a physician as the primary referral source. Other
health professionals (primarily social workers) were by far
the most important professional referral agent.
One possible explanation for the apparent lack of phy
sician involvement in the process of institutionalizing the
frail elderly may be found in the study's sample. This
study is looking only at those elderly who have relocated
to an ACLF, and hence does not include data on the elderly
who have been newly relocated into nursing homes. Possibly,
when physicians are involved in this process, they tend to
refer ego to this later type of a facility. This would


189
links were primarily with relatives. Relatives were con
nected with ego by on average 6.0 material links. Yet, non-
relative close others were still involved with an average of
1.2 material exchanges with ego.
Unlike before the move when ego's greatest number of
links were reciprocated, after moving into the ACLF ego was
predominantly dependently linked to his/her primary network
members. Reciprocated links were next most frequent and
instrumental links became practically nonexistent (see Table
10-4). In fact, in the entire sample, only five instru
mental links were identified at Time 2, and these were all
in ego's relative subsector.
Much of the demonstrated change in the nature of the
relationship between ego and his network can be accounted
for by the more inclusive approach to linkage measure taken
at Time 1. As outlined in Chapter Five, at Time 1 linkage
measurement took into account past services rendered by ego
to network members in an effort to include the "carry over"
obligation dimension of exchanges in the analysis of the
relationship between ACLF entry and reciprocity (Gouldner,
1960). Thus, even if ego was not currently doing for a net
work member in any of the measured areas, if ego had
rendered personal assistance to alter in the past a link
from ego to alter was counted.


223
This means that the more ego was able to maintain an
even give and take with his/her primary network, particu
larly with nonrelative network members, prior to ACLF entry,
the higher was the frequency of visiting by ego's closest
other after ACLF entry. As discussed earlier, tie recipro
city may act to encourage network members to continue to do
for ego. Maintaining contact with ego is a principal way of
expressing this function. Given that reciprocity explained
contact frequency by ego's network as a unit, it is not
surprising that the network member that ego is closest to
also is affected by the reciprocity "push," thereby main
taining contact with ego after the move.
Furthermore, as was proposed with the discussion of the
findings on density, the network unit may indirectly express
their desire to continue to do for ego by supporting ego's
closest other's attempts to maintain contact with ego after
the move rather than by personally continuing to visit ego.
This is particularly indicated both by the large effect of
nonrelative reciprocity on tie duration as well as qualita
tive data from interviews with ego's closest others.
As with density, reciprocity had a much lower effect on
speaking. Only when the effect of reciprocity of ego's
nonrelative network is regressed on Time 2 closest other
speaking does a significant relationship emerge between
reciprocity and speaking. Thus, this too, serves to


248
process is also in need of being corrected, as these profes
sionals are primary referral sources for the public.
In addition to the importance of having knowledge of
the ACLF option, socioeconomic and attitudinal barriers also
limit appropriate ACLF utilization. Although socioeconomic
status and race did not explain ego's presenting health
severity, going home was explained by ego's race and socio
economic status. In terms of cost, while ACLFs unquestion
ably present the elderly and/or their network members with
constant economic demands, the cost of ACLF care is approxi
mately one-half that of nursing home care, and depending on
the extent of ego's care needs may be cheaper than the cost
of home care.
While a collection of government programs have made it
possible for ego and/or network members to reallocate the
financial responsibility for ego's home care or nursing home
care to the government, these options are relatively limited
for the payment of ACLF care. Thus, for many the ACLF
option is a greater personal expense than nursing home care
or home care. A need to rethink long-term care policy
incorporating an ACLF option clearly exists.
In terms of cultural or attitudinal barriers, while it
would be foolish to try to attempt to make ACLFs more ap
pealing than one's own home, attempts to make them more
attractive might well center on maximizing their "homelike"
nature. It then follows that any move towards improvement


124
significant relationship between state-financed and private
payers in terms of ego's total personal network size, net
work density or degree, the proportion of instrumental
links, or the mean network visits, speaking, or writing to
ego (see Appendix I, Table 1-3).
Private payers had a significantly higher proportion of
reciprocated links in both their total primary network
(p < .001) and in their relative subsector (p < .005) They
also had a significantly lower proportion of dependent links
in both their total primary network (p < .005) and relative
subsector (p < .05) than did state-financed residents.
Additionally, private payers perceived their relationships
with the members of their primary network to be more bal
anced than did state-financed residents (p < .05).
This indicates that those whose ACLF care is state-
financed have generally been more dependent on their primary
network for assistance than the private payers at the point
of their move into the ACLF. They have not been able to
repay their network for services rendered to the same degree
as those with more financial resources. Thus, it is not
surprising that their networks looked for state help to
relieve them of one more ego related "burden."
This relationship did not remain when ego's nonrelative
subsector was analyzed. There was no association with link
age directionality in ego's nonrelative sector and ego's
socioeconomic status, regardless of whether directionality


CHAPTER fags
SIX THE PARTICIPANTS: THE NEW
RESIDENTS 97
Presenting Demographic and
Health Profile 97
Morphological Network
Characteristics 100
Range 101
Density and Degree 103
Interactional Network
Characteristics 105
Tie Content and Directedness . 105
Frequency and Duration Ill
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
Referral 153
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 174
Place of Residence 174
Perceived Fit 177
Ego's Health 179
Alter's Response 181
Interactional Network
Characteristics 183
v


239
was demonstrated to influence both the source of ego's label
and the severity of ego's presenting health status.
The higher the intensity of ego's network bonds, the
more likely the source of ego's "out of place" label was a
professional rather than an informal network member. The
intensity of ego's total primary relationships had the
greatest effect the source of the elderly's "out of place"
label, indicating that it is the combined intensity of
ego's relative and nonrelative network relationships that is
most critical in explaining the labeling process. If both
of these sectors are closely bonded to ego, they are more
likely to share a sense of willingness to "do for" ego and,
hence, are more likely to tolerate ego's behavior and not
label it "out of place." However, if only one sector is
closely bonded to ego, the other may interject an "out of
place" label on ego's behavior other than a professional and
influence the remaining portion of ego's network to assume a
similar attitude.
Furthermore, no relationship between reciprocity and
labeling emerged and the effect of reciprocity on ego's
presenting health severity was only demonstrated at p < .10.
Thus, only weak support for the hypothesized relationships
was shown (Gouldner, 1960; Horowitz and Schindelman, 1983;
Wentowski, 1981).
The effects of both intensity and reciprocity on ego's
presenting health were relatively weak, and secondary to


130
The only association between linkage direction and
ego's health was in the proportion of instrumental links in
ego's total network, and this was only for ego's level of
self-care ability. Ego's level of self-care impairment was
inversely related to this directionality measure (p < .05).
There was no relationship with ego's health and the propor
tion of dependent or reciprocated links or in ego's per
ceived balance of the give and take with his/her network
members. This indicates that, in general, the pattern of
material links with ego and his/her network was not influ
enced by ego's health status. Rather, as was discussed
earlier, ego's socioeconomic status was a much more impor
tant variable.
While network size (both as defined in this study and
with the further requirement of the existence of at least
one material link with ego) was not significantly related to
ego's health, the mean network size of those in poor physi
cal and mental health was generally smaller than the network
size of those whose presenting health was higher. The lack
of a significant relationship by size and mental health
status runs contrary to the results reported by Pattison,
DeFrancisco, Wood, Frazier, and Crowder (1975) and
Solkovosky et al. (1978). However, neither of these two
studies controlled for any structural variables when they
examined the relationship between ego's network size and


39
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 prob
ably be to an institution which provides ego with more
intensive health care, such as a hospital or nursing home.
In conclusion, after reviewing the emergence and devel
opment of network theory and outlining the key components in
this framework, network variables were related to the pro
cess of ACLF relocation. Tie intensity, tie reciprocity,
and network density were identified as being centrally im
portant 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.


16
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.
Mgxghfllp.glca.l_ Co n cep ts
Network analysis can focus on the morphological char
acteristics of networks and/or interactional network vari
ables. As delineated by Mitchell (1969:12), "the morpho
logical characteristics refer to the relationship or pat
terning of the links in the network in respect to one an
other." 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, dur
ability, intensity, and frequency. While interactional
criteria include qualitative as well as quantitative dimen
sions, a network's morphological properties are solely quan
tifiable variables. Furthermore, as pointed out by Hammer
(1981), unlike qualitative variables whose first order


323
Table K-lContinued
Focal
Network
Total
(N =
Primary
70)
Relative
(N = 67)
Connectivity
Measure
Logit
SD
Logit
SD
Network bondedness,
Time 1
.34** .16
.15
.11
Closest other
intensity, Time 1
-.01
.18
.12
.18
Reciprocity
"objective," Time 1
.95
1.74
1.12
1.85
Reciprocity
"subjective, Time 1
-.16
1.20
-.80
1.29
*p < .10.
**p < .05.
a
While the table includes both measures of reciprocity,
they were regressed on returning home separately. The
reported coefficients of the remaining variables are
from the regressions with the objective measure of
reciprocity.


APPENDIX D
INITIAL QUESTIONNAIRE
ADDRESSED TO RESIDENT


178
I couldn't handle it in my own home anymore.
I'm too weak now, and I'm blind. They all loves
me here. (a female resident)
It's like living in a one-room house. As you
get older you don't care for the responsibilities
of a big house. It's a lot easier here. We
have a place to eat. (a resident couple)
It's like a family here. Now I have five
ladies around me to talk with and help. Living
in a group is better than living by yourself. I
could never afford to live at home anymore.
By the time you pay utilities and get someone
to care for you, it is just too expensive.
(a male resident)
These findings suggest that ACLFs were perceived more
favorably than Tobin and Lieberman's (1976) homes for the
aged. Possibly, ACLFs exemplify the kind of elderly-focused
living arrangement they are calling for in their implica
tions for practice. Yet, while these positive feelings pre
dominated, in addition to the problems identified with
managing ego's physical care, problems related to what
Goffman (1961) has described as the institutionalization of
the place were also perceived by the residents and their
networks. Residents were dissatisfied when they perceived
their ACLF lifestyle as being either too structured or
lacking in adequate personal freedom. Along these lines the
following comments were expressed:
It's a little difficult life. . It's more
structured than I'm used to. (a female resident)
I'm doing as well as can be expected. I've
adjusted. I can't eat as often as I did. I used
to eat small amounts frequently. . You're
not your own boss anymore. (a female resident)


Table J-4Continued
Focal Network
Connectivity Measure
Total Primary
(N = 77)
Relative
(N = 74)
Nonrelative
(N = 38)
b
SD
b
SD
b SD
Reciprocity--"objecti ve "
-.49
.82
-.07
.82
.25 .60
Reciprocity--"subj ective"
.18
.61
.01
.63
.47 .69
R2
.03
.06
.28
*p < .10,
**p < .05.
***p < .01.
a
While this table includes both measures of reciprocity, they were regressed on ego's
health separately. The reported coefficients of the remaining variables are from the
regression with the objective measure of reciprocity.
320


172
presenting physical or mental health status, socioeconomic
status was found to explain both the source of ego's "out of
place" label and the source of ACLF referral. Having ego's
care financed by the state increased the likelihood of both
formal labeling and formal referral. Finally it was demon
strated that the network source of ego's labeling and ACLF
referral is likely to be consistent. These relationships
are illustrated in Figure 9-1.


Table J-4
Variable effects on ego's presenting physical health status, by connectivity
measure and focal network, unstandardized regression coefficients
Focal Network
Total Primary
Relative
Nonrelative
(N = 77)
(N = 74)
(N = 38)
a
Connectivity Measure
b SD
b SD
b SD
Density
.02**
.01
.03**
.01
.01
.01
SES
-.17
.66
-.41
.69
.28
.75
Sex
.41
.46
.35
.45
.19
.63
Race
-.40
.68
-.19
.73
.86
.83
Network bondedness
.07
.08
.05
.06
-.16
.12
Significant other bondedness
.04
.09
.02
.09
-.08
.12
Reciprocity--"objective"
-.31
.79
.16
.81
.57
.12
Reciprocity"subj ective"
2
.19
.58
-.29
.62
.52
.75
R
.10
.10
.13
Degree
.00
.08
-.11
.08
.33**
.12
SES
-.40
.67
-.65
.70
-.20
.69
Sex
.09
.46
.22
.46
-.08
.54
Race
.04
.69
.48
.73
.70
.75
Network bondedness
.06
.08
.05
.06
-.19*
.11
Significant other bondedness
.03
.09
.01
.09
.00
.11
319


53
and Cohen and Rajkowski (1982), which reveal that normative
second-order constructs of friendship may bear no relation
ship to the definitions in use by study respondents.
Sokolovsky and his associates' 1978 study found self-pro
claimed loners who, while denying friends, had large complex
networks involving an assortment of material and instru
mental exchanges. On the other extreme, Creecy and Wright
found among their black rural native elderly a very non-
restrictive operating definition of friendship. In this
sample it seemed that friendship was equated with friendli
ness, 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


PRIMARY SOCIAL NETWORK:
PREDICTORS AND CONSEQUENCES OF
ENTERING AN ADULT CONGREGATE LIVING FACILITY
By
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


86
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 infor
mation source. Ten responses were possible: living alone
without any help (0), living alone with the help of family
and friends (1), living alone with the help of formal agen
cies (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), located in a hospital, but
planning to return to an ACLF (7), located in a hospital and
planning to return home (8), living in same ACLF (9), and
living in different ACLF (10) were aggregated into the
dichotomous variable: returned to home environment (0, 1,
2, 3, 4, 5, and 8), or remained in an institutional setting
(6, 7, 9, and 10).


41
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 behaviorhelp ren
dering 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, serious
ness 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 per
sons involved in the relationship have no other ties which
are closer. Thus, it is a lack of mutual emotional bonded
ness 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.


152
sources of ego's "out of place" label (see Table 8-1).
Only 7.4% of the respondents identified ego as the source of
the label. Conversely, approximately 61% of the respondents
identified a member of their personal network as the source
of this label. Thus, as ego only rarely identifies
him/herself as "out of place," the focal network for
studying this process was not appropriate. Rather than
consider ego the anchor, the network of ego's closest other
is most likely to predict who suggested that ego no longer
fit in his/her current environment.
Returning to the proposition posited by Granovetter
(1973, 1981) and Horwitz (1977)that the degree of openness
or density in a person's network is directly related to the
number of information channels connected to himone would
then hypothesize that if ego's closest other belongs to an
open or low-density network, he/she has a more diverse know
ledge base and, hence, is more likely to identify ego's
condition as a problem. Alternatively, if this person
belongs to a relatively closed network, it is less likely
he/she will recognize ego's condition as a problem. Rather,
it is more likely that the source of this label will then be
a professional.
In conclusion, the hypothesized direct relationship
between the connectivity of ego's network, the degree to
which there was an even give and take (either perceived or


290
7. Which of the following best compares the emotional
atmosphere in ego's current residence with that
experienced at (insert name of former ACLF)?
(0) The caregivers here seem to care more about
ego
(1) The caregivers here seem to care about the
same for ego
(2) The caregivers here seem to care less about
ego
8. Could you please identify any problems that you or
ego are currently experiencing? [Go to (12).]
9. How are things going for ego now?
10. How would you describe the physical care ego has been
receiving?
(0) The caregivers here give ego excellent
physical care
(1) The caregivers here give ego adequate
physical care
(2) The caregivers here give ego less than
adequate physical care
11. How would you describe the emotional atmosphere at the
ACLF?
(0) The caregivers here seem really to care
about ego
(1) The caregivers here are pleasant, but don't
seem really to care about ego
(2) The caregivers here are not pleasant and
do not seem really to care about ego
12. Which of the following best describes ego's current
living condition?
(0) Ego is living alone without any help
(1) Ego is living alone with the help of
family/friends
(2) Ego is living alone with the help of
formal agencies
(3) Ego is living alone with the help of family
and friends and formal agencies
(4) Ego is living with family/friends
(5) Ego is living with family and friends and
being helped by formal agencies


70
ego's current self-care abilities as they were assumed to be
the most knowledgeable and objective sources of this infor
mation.
While it was recognized that the "key informant ap
proach" to information about ego's network would undoubtedly
"slant the truth" in the direction of ego's (or ego's clos
est 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 ques
tioned 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 collec
tion was maximized by (1) quashing ulterior motives of the
informant, (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 ex
plaining to the informants that the researcher was in no
position to alter the existing situation. Bars to sponta
neity were lifted by assuring the informants of


APPENDIX C
INDEX OF INDEPENDENCE
IN ACTIVITIES OF DAILY LIVING


30
Once the behavior of the potential ACLF resident is
defined as "out of place," 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 pattern, or
role, comes to be the dominant role by which the individual
is identified. Lemert (1951) conceptualizes this transform
ation of self as the movement from a primary, or situation-
ally 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 attri
bution of the new label (Schur, 1971). Future actions are
anticipated to be deviantand they are likely to be so.
The power of suggestion (particularly by those in our imme
diate social world) is great. As others come to define
people, so they tend to define themselves. The prospective


265
The second group is to include all of the adults you
feel close to (excluding relatives and other residents
at this ACLF) and have been in contact with on a fairly
regular basis during this past year. [List network in
charts at the end of the questionnaire. Record answers
to (10)(12) in same charts.]
Now for each person you identified, I am going to
ask you a series of general questions about your
relationship.
10a. What is the person's name?
10b. What is the basis of your relationship? (sibling, child,
spouse, friend etc.)
10c. About how long have you been acquainted with ( )?
Note: Score (Id), (le), and (If) in terms of times
per week, times per year, or times per month.
lOd. On average, about how often have you seen ( ) during
this past year?
lOe. About how often have you talked with ( ) during this
past year?
lOf. About how often have you exchanged letters with ( )
during this past year?
lOg. Does ( ) give you any financial assistance?
lOh. Does ( ) give you personal assistance (i.e., rides to
the doctor, take you shopping, do your laundry) when
you need it?
lOi. Do you receive gifts from ( )?
10j. Do you provide ( ) with any financial assistance?
10k. Do you provide ( ) with any other personal assistance
now, or have you in the past?
101. Do you give ( ) gifts?
11. Now, for each person you identified I am going to ask
you some questions concerning how you feel about that
person. Please respond with one of the following:
Not at all true of him/her (NT), somewhat true of
him/her (ST), or very true of him/her (VT).


116
The network characteristics explored were size (of both
the personal network as defined in this study and that
portion of that network which are also materially linked to
ego); density and degree; mean network emotional bondedness
to ego; the proportion of network links that are reciprocal,
dependent, and instrumental; the proportion of ties per
ceived as balanced; and the mean frequency of visiting,
speaking, and writing contact between ego and his/her per
sonal network.
The characteristics of both ego's total personal net
work and relative and nonrelative subsectors were analyzed.
However, as the network definition became more restrictive,
the sample size became smaller. This made it harder to
reject the null hypothesis of no group differences, and may
at least in part account for the sparsity of significant
between group differences in regard to ego's nonrelative
subsector. For instance, only 46 respondents had a large
enough nonrelative network to analyze group differences in
density and degree (a minimum of three members were needed).
Similarly, only 63 respondents had a large enough nonrela
tive subsector to analyze between group differences in net
work emotional bondedness to ego and network contact pat
terns with ego. And, only 51 respondents had at least one
material link in their nonrelative subsector.
A multiple analysis of variance was performed to allow
the researcher to assess the effects of each these


INITIAL QUESTIONNAIRE
ADDRESSED TO RESIDENT'S CLOSEST OTHER
My name is Mary Bear. I am doing research for a
University of Florida study on the life styles of older
persons. More specifically, the study focuses on the
process by which older people decide to live in Adult
Congregate Living Facilities (ACLFs) and the effects of
these decisions on their family and friendship
relationships.
I obtained your name and the information necessary to
contact you from ( ). The purpose of this questionnaire is
to obtain information on how it was decided that ego
(substitute name of resident for ego throughout the
questionnaire) would move into an ACLF and how that move has
affected ego's family and friendship relationships. It
will take about one hour. There are no right or wrong
answers. All of your answers are confidential. They will
not be shared with ego or anyone else. Would you please
give me permission to ask you some questions?
Informed consent obtained not obtained
(Only proceed if informed consent is obtained.)
1. I would like to begin with some questions regarding
ego's move into an ACLF. Could you briefly explain
what ego's living situation was like at that time?
(Was ego living alone? With a family member? Was
ego having any problems getting along? If so, what
were they?)
2. Who first suggested that ego might have to move into
another living situation?
A relative of ego
A personal contact of ego
Ego's doctor, or another health professional
(i.e., a nurse or a social worker)
Ego determined it him-/herself
271


65
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.


240
that of density (see Chapter Nine). Two explanations are
offered. Possibly, as suggested in Hammer (1981), the "posi
tive" network structural characteristichigh densityis in
fact a more "supportive" force than are the positive inter
actional characteristics, high intensity, and high recipro
city. Alternatively, perhaps the intensity and reciprocity
of ego's ties are equally as important as density in de
laying ACLF entry. The degree of these variables may have
been higher when network members began to attempt to accom
modate ego's environment to facilitate keeping him/her at
home but, by the time of ACLF entry the initial degree of
these characteristics had declined. For intensity, the
strain in caring for ego may have caused the decline in
relationship intensity. For reciprocity, the decline in
ego's health may have caused the decrease in ego's ability
to reciprocate. To answer these questions future research
will need to either extend its longitudinal time frame
further backward or incorporate some retrospective ques
tioning on these variables.
While the controlsrace and sexdid not explain the
process of ACLF entry, the socioeconomic status of the
elderly did have an effect on labeling and referral. If the
new resident's care was being financed by the state, a
professional was more likely to be the source of both prob
lem labeling and ACLF referral. This is probably due to the


4
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 substi
tute 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 re
ported 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 explora
tion of alternatives to nursing home placement. As a part
of this movement an intermediate continuum of living ar
rangements for those who no longer "fit comfortably" in
private homes, but do not yet demand the level of care pro
vided by nursing homes is emerging. Included in this inter
mediate range of housing alternatives are such living ar
rangements 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


144
Nursing homes are like the plague, (a female
resident)
Not only did the residents not want to be in nursing
homes, they also felt that they did not belong there. While
it may be alright for them to move to an ACLF, a nursing
home definitely was not the appropriate place for them.
ACLF's were recognized as places of more personal freedom
than nursing homes, and by many respondents they were also
seen as a place of more freedom than would be experienced in
their childrens' homes. As one resident so aptly stated,
"This is the best way to optimize my independence. I can do
for myself here. ... I am more independent here than I
would be living with my daughter." Yet, while a greater
sense of "homeyness" seemed to be associated with ACLFs than
with nursing homes, they were definitely recognized as being
different than living in one's own home. The move was the
best available alternative, but the ACLF "just isn't like
home." As one respondent stated, "It's a new world here."
In fact, while nearly half of the new residents stated
that they had recognized their need to move to the ACLF,
approximately one-third felt that this move was unnecessary.
Thus, as relatives and professionals went about orches
trating ego's move, it was frequently against ego's will.
Consistent with our social norms of saving face for our
family, the residents frequently made excuses for their
family's behavior, playing down any conflict they may have


110
dependency ratio in this study in the nonrelative vs. rela
tive sectors), whereas, nonmaterial links between nonrela
tive personal network members are probably less likely to be
dependent than those in the relative subsector.
In fact, in this study nonmaterial network linkages
were stronger between ego and the nonrelative sector (mean
bondedness was 33.1) than between ego and the relative
sector (mean bondedness was 31.0). The mean bondedness
between ego and his/her total primary network was 32.1.
Although the emotional bondedness measure used does not
exclusively indicate reciprocity, it does take it into
account.
The measure of ego's perceived tie equivalency took
into account both material and nonmaterial linkages between
ego and alter. Thus, the higher proportion of "balanced"
relationships" reported verses the computed proportion of
reciprocated material links may in part be explained by
ego's incorporation of the nonmaterial component into this
subjective measure. On average 73% of the total ties, 67%
of the relative ties, and 69% of the nonrelative ties were
perceived as balanced. However, given that the norm of
reciprocity actually exists, and hence, that relatives
"should" be repaying ego for help rendered in the past,
these higher proportions may also reflect ego's desire to
present a normative, nondeviant picture of his/her network
relations.


199
Table 11-1. Effects of ego's total network on staying in an
institution, standardized regression
coefficients (N = 70)
Variable Name
Total
B
Network
SD
Density, Time 1
1.82
.03
Closest other intensity, Time 1
.29
.17
Reciprocity"objective," Time 1
.92
1.89
Network bondedness, Time 1
3.25*
.18
Sex
-.08
1.17
Socioeconomic status
-3.97*
1.86
Physical health, Time 2
12.64*
1.14
Race
-4.26*
1.86
*p < .05.


51
help, resulting in longer symptom duration prior to hospi
talization. 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 hospi
talization of ego was not as positively perceived accounting
for the reported inverse relationship between network inten
sity 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 symptomatologyand thus is not particularly
relevant to the proposed studyit bears mentioning due to
both the conclusions it reached on the relationship between
social network characteristics and rehospitalization and its
methodological approach.


163
effect of closest other intensity on delaying the move to
the ACLF.
The importance of ego's nonrelative network is further
emphasized by comparing the impact of network variables by
focal network (see Appendix J, Tables J-3 and J-4). While,
as was explained earlier, the density and the degree of
reciprocity in ego's total network have a greater effect on
ego's presenting health severity than do these subsector
characteristics, when the effects of network characteristics
are considered as a unit the greatest proportion of variance
in both ego's presenting mental and physical health is ex
plained by nonrelative network variables.
The predicted positive relationship between network
bondedness and ego's presenting health severity was not
significant. In fact, as ego's presenting physical health
worsened nonrelative bondedness tended to decrease
(p < .10). The lower ego's presenting physical health
status the less emotionally bonded ego tended to be to
nonrelative network members. If a highly bonded network
does keep ego home longer, thus allowing ego's presenting
health status to worsen, over time this emotional bondedness
may decrease due to the strains of maintaining ego at home.
Nonrelative close others may be less resilient to the de
mands of caring for an ailing network member than are rela
tives. This would result in no bondedness difference by


105
Interactional Network Characteristics
Tie Content and Directedness
Appendix H also presents the means and standard devia
tions of the interactional characteristics of the new resi
dents' networks. Data were collected on the interactional
characteristics content, directedness, duration and fre
quency for both ego's total adult primary network and rela
tive and nonrelative primary subfields. In regards to con
tent, information on both material and nonmaterial links
between network ties was compiled. Material links were
defined as the transfer of personal assistance, gifts, or
financial assistance from either ego to alter or from alter
to ego.
Interestingly, at the time of the new resident's move
into the ACLF ego was connected to his/her network members
by a fairly large number of material linkages. The mean
number of linkages in the total network was 9.7, in the
relative sector, 7.2, and in the nonrelative sector, 2.5.
It is not surprising that relatives have more material links
to ego than nonrelatives. However, the finding that, on
average, 2.5 material links exist between nonrelative net
work members and ego lends further support to Cantor's
(1979) finding of the importance of friends and neighbors as
an informal support system for the elderly.
When the additional criterion of material linkages is
demanded for alter to be included in ego's network, the mean


BIOGRAPHICAL SKETCH
Mary J. Bear was born on March 24, 1955, in Milwaukee,
Wisconsin. Mary married Roger Bear in 1979. In 1981, their
son, David, was born and the birth of their daughter,
Denise, was in 1985. Mary graduated Magna Cum Laude with
the Bachelor of Science in Nursing degree from Vanderbilt
University in 1976. In 1978, a Master of Science degree in
nursing with a dual focus in community health and aging was
earned from the University of Colorado. Her doctoral study
in medical sociology and the sociology of aging resulted in
earning a Ph.D. from the University of Florida in 1986.
Currently, Mary is working part-time as a visiting
assistant professor in the University of Florida's graduate
community health nursing program. Her research interests
are in the effects of social networks on the process of
institutionalizing the elderly and the consequences of
institutionalization on these networks.
347


42
While Lowenthal-Fiske (1964) did not incorporate care
fully 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 resi
dents 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 rela
tives, and those living with distant relatives. Distant
relative relational systems were less likely to try pre
alternatives, had less tolerance for symptoms, and acted
most quickly to hospitalize the patient. Thus, patients


Table K-2Continued
Type of Contact
Visiting
Speaking
Writing
Time 2
Time 2
Time 2
Focal Network
b SD
b SD
b SD
Percentage of variance by
Time 1 contact
Net percentage of variance
.34
.22
.21
.19
.42
.04
Eelaiijye IE = £Q1
Visiting, Time 1
.36****
.10




Speaking, Time 1


.49****
.12


Writing, Time 1




.42***
.11
Density, Time 1
.03**
.01
.02**
.01
.02
.01
Degree, Time 1
.01
.09
.02
.08
-.02
.08
Closest other intensity, Time 1
-.01
.07
-.05
.07
.05
.07
Network bondedness, Time 1
-.08
.05
-.07
.05
-.12
.06
Reciprocity"objective," Time 1
1.30**
.67
.96*
.60
-.92*
.49
Reciprocity"subjective," Time 2
.44
.51
.51
.44
.72**
.35
Sex
-.40
.35
-.08
.31
-.27
.37
Race
-.18
.53
-.02
.47
.00
.58
SES
-.44
.49
-.62
.44
-.62
.51
Mental health, Time 2
.05
.13
-.21*
.11
.07
.14
Physical health, Time 2
-.03
.08
-.08
.07
.08
.07
Location, Time 2
-.07
.62
.29
.55
-.02
.68
325


69
Of interest were both the resident (otherwise referred
to as ego) and the resident's primary or ego-centered net
works. 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 nec
essary 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 informa
tion, 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


CHAPTER TWELVE
CONCLUSIONS:
THEORETICAL AND PRACTICAL IMPLICATIONS
This research was a longitudinal study oriented toward
understanding the effect of the elderly's networks on the
process by which the elderly enter and settle into ACLFs and
continue to maintain their primary network ties. A combin
ation of qualitative and quantitative methodologies were
used with both new residents and their closest others ser
ving as key informants.
The initial interviews provided data on ego's health
status, the process by which the ACLF was entered, and the
structural and interaction characteristics of ego's network.
Follow-up interviews determined ego's health status and
perception of the ACLF at that time, ego's location, as well
as the degree to which ego's ties had endured after ACLF
entry.
Previous chapters have examined the findings of this
work at length. In this chapter the theoretical implica
tions of these results are summarized and future research
directions are addressed. Additionally, practical implica
tions drawn from this research for ACLF caregivers, the
health professionals involved in caring for ego, and ego's
network prior to ACLF entry are outlined.
233


345
Sokolovsky, Jay, C. Cohen, D. Berger, and Josephine Geiger
1978 "Personal networks of ex-mental patients in a
Manhattan SRO hotel." Human Organization 37:5-15.
Streib, Gordon
1978 "An alternative family form for older persons:
Need and social context." The Family Coordinator
27:413-420.
1983 "The frail elderly: Research dilemmas and research
opportunities." The Gerontologist 27:40-44.
Streib, Gordon, Edward Folts, and Mary Anne Hilker
1984 Old HomesNew Families: Sha.red_Livipg for, .the
Elderly. New York: Columbia University Press.
Swafford, P.
1980 "Three parametric techniques for contingency table
analysis: A nontechnical commentary." American
Sociological Review 1980:664-690.
Tobin, Sheldon, and Morton Lieberman
1976 Last Home for the Aged. San Francisco,
California: Jossey-Bass Publishers.
United States Bureau of the Census
1984 Bta-tisbical. .Abstract of. ..the .Unit.ed._S.ta.tes.
Washington: U. S. Government Printing Office.
Vaghn, Christine, and L. Leff
1976 "The influence of the family and social factors on
the course of psychiatric illness: A comparison of
schizophrenic and depressed neurotic patients."
British Journal of Psychiatry 129:125-137.
Verbrugge, Louis
1985 "Gender and health: An update on hypothesis and
evidence." Journal of Health and Social Behavior
26:156-182.
Wan, Thomas, and William G. Weissert
1981 "Social support networks, patient status, and
institutionalization." Research on Aging 3:93-101.
Ward, Russel, Susan Sherman, and Mark LaGory
1984 "Subjective network assessments and subjective
well-being." Journal of Gerontology 39:93-101.


160
Hammer's (1963) posited explanation of the increased
supportive nature of dense verses loose-knit networks is
also a plausible rationale for these findings. A dense
network structure facilitates intranetwork support for
The substitution of degree for density in the regres
sion equations generally resulted in a substantial lowering
in R-square, indicating that density is also more useful
than degree in explaining ego's presenting health status.
Furthermore, while the proportion of ego's network members
who were in regular contact with each other was directly
related to the severity of ego's presenting health status,
once again, there was a tendency for the degree of ego's
total primary network and relative subsector to decrease as
ego's presenting health status worsened (see Appendix J,
Tables J-3 and J-4).
As with the relationship with degree and labeling and
referral, this result is directly opposite to what was pre
dicted. Once again, an explanation may be found in the con
founding variable, network size. While those with decreased
presenting health status belong to networks where a higher
percentage of members are in regular contact with each
other, this does not imply that these networks are in fact
larger. Conversely, while there is not a significant dif
ference in network size by ego's health status, size does
tend to decrease with the increased severity of ego's pre
senting health (see Chapter Seven). The decreased size of


204
Contact Frequency
The effect of network variables differed by focal net
work and the type of contact being analyzed. The density of
ego's total primary network, the density of his/her relative
subsector, and the proportion of reciprocated links in ego's
relative subsector, as well as the control variablesego's
location at Time 2, ego's mental health at Time 2, and Time
1 contact levelsall were significantly related to ego's
total primary network and relative subsector's frequency of
visiting and speaking with ego at follow-up. There was no
relationship with total primary network and relative
visiting or speaking contact frequency at follow-up and
network intensity, degree, or the subjective measure of
reciprocity, nor with the control variablessex, race,
socioeconomic status, and ego's level of physical health at
Time 2 (p >. 05). Alternatively, none of the network var
iables explained nonrelative visiting and speaking at Time
2. The significant variables for this subsector were the
controls. Time 1 contact levels, and ego's location at Time
2 each helped explain nonrelative visiting and speaking
contact at Time 2 (see Appendix K, Table K-2).
In terms of written contact, for ego's total and rela
tive networks by far the greatest percentage in the variance
in Time 2 contact levels was explained by Time 1 levels, the
only other significant variable being reciprocity, with both
objective and subjective measures significant.


ACKNOWLEDGMENTS
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.
iii


101
Range
Range refers to the size of the delimited portion of
ego's network. As stated earlier, after identifying all
those adult relatives and "close" others ego was in regular
contact with during the past year, this measure was refined
by the existence of two criteriacontact with ego at least
several times during the last year, and the presence of
either a material link or a nonmaterial link (defined via
Snow and Crapo's Emotional Bondedness Scale) between ego and
alter.
The mean size of this total primary network of ego was
7.4, with subnetwork means of 2.8 for the nonrelative sector
and 4.7 for the relative sector. However, the wide range in
network size should not be overlooked. For ego's total
primary network, approximately 16% of the respondents had
networks greater than 11.5 and 16% had less than 3.3 network
members. Variations in ego's relative network were such
that approximately 16% of the ego's relative networks were
larger than 7.5 and 16% were smaller than 1.7, and 16% of
the residents nonrelative primary networks had more than 5.6
and 16% had no members in this sector at all.
Meaningful comparisons of these results with other
findings in the literature require at least comparable
network delimitation methods. For the elderly, the closest
measure that this researcher could find was in Cantor's
(1979) study of the elderly's informal support networks. The


122
significant differences by race emerged in ego's contact
with his/her nonrelative subsector, if ego was nonwhite, ego
was more likely to be in both speaking (p < .01) and vis
iting (p < .05) contact with his/her relatives and in
speaking contact with his/her total primary network
(p < .05) and less likely to be in written contact (p < .05)
with his/her total primary network and relative subsectors.
As this relationship was revealed controlling for the socio
economic status of ego, any explanation must be found else
where. Possibly, nonwhites were in closer proximity to
their network, facilitating more network visiting. However,
if this is so, one wonders why the geographical dispersion
of ego's network varies between nonwhites and whites. Fur
thermore, geographical dispersion would not totally account
for the differences in verbal and written contact between
whites and nonwhites. An educational difference between the
two groups may be partially responsible, with nonwhites
having less education, and hence being less comfortable with
written communication. Another explanation would be cul
tural. As one nonwhite respondent said, "We don't like to
write. ... We feel it is so much more personal to call."
Finally, although, the objective measure of tie dir
ectionality revealed no significant difference between
whites and nonwhites, nonwhites were significantly more
likely to perceive that the relationship with their primary
network members was balanced (p < .005). Although the


5
tools have begun to surface (Christ, Visscher, and Bates,
1985; Kleh, 1977; Sherwood, Morris, and Barnhart, 1978).
The Adult Congregate Living Facility
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 resi
dents. Personal services include such services as indi
vidual assistance with or supervision of essential activi
ties of daily livingsuch as eating, grooming, dressing,
and ambulationand the supervision of self-administered
medication.
A key difference between ACLFs and nursing homes is
that, unlike nursing homes, ACLFs are not required to pro
vide professional therapy for their residents. Rather, they
act in a paraprofessional manner "supervising" self-admin
istered 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


145
been experiencing with their families. Yet, 16% of them
openly expressed the anger they felt towards their family
regarding the move. Some good examples of these feelings
are illustrated in the following quotes:
I am ashamed to be here. ... I have not told
anybody where I am. (a female resident)
[Ego] just doesn't want to leave her own
home. . Yet, it is so expensive getting
someone to cover her care there. It is especially
difficult getting someone at night, and this is
when [ego] is most confused. Neighbors stop in,
but they don't really help. ... (a son)
It's alright here. . Living with other
people has its problems. I would prefer living
with my friends, but they aren't able to take
care of me. (a female resident)
Thus, Streib's (1978) concept of an amalgam group is
probably just as appropriate for describing this type of
living situation as it is for describing share-a-homes. The
ACLF is recognized by the residents as being less personal
than living in one's family, but as a situation with more
freedom than what exists in the institutional structure of
the nursing home. Therefore, given the similarities in
these residents' reactions to ACLFs with those expressed in
Hilker's study of share-a-home residents (1983), the delin
eation between these two categories is probably artificial.


10
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
problematic?
How did the ACLF resident become informed of
ACLFs?
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
entry process?
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


117
independent variables on the outlined network character
istics while controlling for the effects of the other inde
pendent variables. However, as each of the health indica
tors are highly correlated, the problems of multicollin-
earity were avoided by analyzing them separately.
Differences by Sex
Controlling for ego's race, socioeconomic status, and
health (both physical and mental), only three of the identi
fied network characteristics were explained by sex. There
was a significant difference between the sexes in network
density, size and in the frequency of contact with ego and
network members. There was no significant difference be
tween the sexes in terms of their total personal network
size (when defined with the additional criterion of at least
one material linkage with ego), network bondedness to ego,
frequency of network writing, or either objective or subjec
tive network tie directionality (see Appendix I, Table 1-1).
In terms of network structure, while the average number
of relations between network members (degree) was not signi
ficantly different between males and females regardless of
whether one looked at ego's total personal network or either
of the identified subsectors, males had a higher total
network density than females (p < .05). Thus, there was a
higher proportion of the theoretically possible links in the
total personal networks of males than of females.


149
than when the residents or their networks are assuming
financial responsibility for ACLF care.
The intensity of ego's network ties was the only net
work variable related to labeling by a professional. There
was no relationship with network reciprocity, density,
degree, or the intensity of ego's relationship with his/her
closest other to the labeling process (see Appendix J, Table
J-l). As the intensity of ego's relationship with his/her
total primary network increased, the likelihood of profes
sional labeling increased (p < .05).
This relationship did not remain significant for rela
tive and nonrelative intensity, although the trend did
remain. These results may be explained by Cantor's (1979)
theory of network compensation. It is not the effects of
these sectors taken separately, but their combined nature
that influences the labeling process.
If both relative and nonrelative sectors are closely
bonded to ego, they are more likely to share a sense of
willingness or obligation to do for ego, and hence are more
likely to tolerate ego's behavior and not label it out of
place. However, if only one sector is closely bonded to
ego, the other sector may interject the "out of place" label
on ego's behavior rather than a professional, and may in
fluence the remaining portion of ego's personal network to
assume a similar attitude.


251
Given that nonrelative visiting was particularly prone
to decline, ACLF managers need to make a special effort to
include these close others in ACLF-orchestrated functions.
Planning reponsibilities could be dispersed by organizing
committees of the healthier residents and giving them some
of this responsibility. Another approach that could be
helpful for the smaller ACLFs would be for them to combine
efforts and alternate their planning responsibilities.
In addition to facilitating visiting contact, telephone
and written contact remain important avenues of communica
tion with network members which need to be maintained. As
barriers within the ACLF have a great effect on phone com
munication with network members after ACLF entry, particular
attention is needed in this area. Simply alerting the new
resident and his/her network of the importance of acquiring
a phone may go along way to decreasing the problem. Having
centrally located portable phones would be a helpful within-
system ACLF response.
While letter writing did not decline at ACLF entry, it
did not increase either. In addition to requiring the
availability of stamps and postcards or envelopes, letter
writing often demands the assistance of staff or network
members. Its importance should be stressed. Allotting a
block of time within the week would be a useful way of
facilitating staff's assistance in this area.


337
Brown, G. W., J. Birley, and J. Wing
1972 "Influence of family life and the course of
schizophrenic disorders: A replication."
British Journal of Psychiatry 125:241-258.
Cantor, Majorie H.
1979 "Neighbors and friends: An overlooked resource in
the informal support system." Research on Aging
1:434-463.
Chappell, Neena
1983 "Informal support networks among the elderly."
Research on Aging 5:77-99.
Christ, Mary Ann, Marie Visscher, and Dorothy Bates
1985 "Variables associated with placement in adult
congregate living facilities." Unpublished.
Coffman, Thomas
1981 "Relocation and survival of institutionalized
aged: A reexamination of the evidence." The
Gerontologist 21:483-495.
Cohen, Carl I., and Henry Rajkowski
1982 "What's in a friend? Substantive and theoretical
issues." The Gerontologist 22:261-266.
Cowgill, D. 0.
1974 "Aging and modernization: A revision of the
theory." Pp. 123-146 in Jaber F. Gubrium (ed.),
Late Life. Springfield, Illinois: Charles
Thomas Publishing Company.
Creecy, Robert F. and Roosevelt Wright
1979 "Morale and informal activity with friends among
black and white elderly." The Gerontologist
19:544-547.
Cubitt, Theresa
1973 "Network density among urban families." Pp. 67-82
in Jeremy Boissevain and J. Clyde Mitchell (eds.),
Network Analysis; Studies in Human Interaction.
The Hague: Mouton and Company.
Dean, John P., and William Whyte
1969 "How do you know the informant is telling the
truth?" Pp. 105-114 in George J. McCall and J. L.
Simmons (eds.), Issues in Participant Observation.
Menlo Park, Massachusetts: Addison-Wesley
Publishing Company.


147
health at the time of ACLF entry. As these dependent
variables are both categorical and interval a combination of
multiple and logistic regression analyses was used. A
logistic regression was done to analyze the categorical
dependent variables as it has been established that ordinary
least squares is not an appropriate methodology for ana
lyzing dichotomous dependent variables (Aldrich and Nelson,
1984; Swafford, 1980). The reasons for this approach are
multiple: (a) the conditional distribution of Y is not
normal, (b) the conditional distribution of Y is noncon
stant, (c) the error term is correlated with the model, (d)
the results are highly sample specific, and (e) there is no
requirement that Y falls between 0 and 1 and values outside
this range are meaningless.
Logistic regression is a model transformation approach.
The untransformed model is "S" shaped, bounded at P = 1 and
P = 0, with P indicating the probability of observing a
response of Y = 1. In this analysis both the probability of
ego being labeled "out of place" by a professional and the
probability of ego being referred to an ACLF by a profes
sional were indicated by Y = 1.
Controls were added for sex, race, and socioeconomic
status as they have been both theorized and demonstrated to
have an effect on health related help seeking behavior
(Freidson, 1970; Gove and Howell, 1974; Horwitz, 1977;
Verbrugge, 1985). Each of these were dichotomously coded


237
continue to fit into their home (Cantor, 1979; Chappell,
1983; Dono, Falbe, Kail, Litwick, Sherman, and Siegel, 1979;
Rundall and Evashwick, 1982; Wan and Weissert, 1981;
Wentowski, 1981), once again, this study's incorporation of
the concept of density is a unique approach in the study of
these questions. Thus, its contribution is significant and
points for a continued need to focus on the effect of the
interconnections between all of ego's primary group members
in theory and research on the process of caring for the
frail elderly at home and institutionalization.
The effect of degree on ACLF entry was consistently
shown to be different from and frequently less than that of
density (see Chapter Nine), demonstrating the noninter
changeability of these two connectivity indicators. As
other studies on the network effects of help-seeking behav
ior have generally focused on density as the indicator of
network connectivity (Hammer, 1963; Horwitz, 1977, McKinlay,
1973, Perrucci and Targ, 1982), clearly differentiating the
explanatory power of these two indicators is another useful
contribution of this study to current network research and
theory.
Furthermore, in terms of labeling and referral, while
the choice of anchor is inappropriate, the consistently
negative relationship between degree and both labeling and
referral results in a new hypothesis emerging from this
study: As the average number of relationships network


92
4. the number of reciprocal material ties
between ego and alter; and
5. the frequency of visiting contact between
ego and alter.
A similar approach to operationalizing this construct
was utilized in a recent work by Lin, Woelfel, and Light
(1985). Duration, frequency, intimacy and emotional support
were also included as construct dimensions. However, they
operationalized intimacy and emotional support via a series
of five questions, rather than through Snow and Crapo's
Emotional Bondedness Scale (1982). An additional important
difference in their methodology was that alter's perception
of their relationship was not included.
In this study the subcomponents were quantified on a
three-point scale. As the Emotional Bondedness Scale meas
ures both intimacy and closeness, its weight was doubled.
Thus, total scores for the five-dimensioned scale could
range from 7 to 21.
Ordering of these subcomponent responses into high,
medium, and low categories was not determined until after
the initial data were collected to maximize the fit between
the theoretical and empirical meanings of intensity. The
frequency distributions of the elements around their median
revealed theoretically meaningful high, medium, and low
categories for all but the duration dimension of intensity.


Table 1-2Continued
Network Characteristics
Sum of Squares
Mean Square
a
F
N
Mean frequency of speaking
Total
12.08
2.31
5.22*
80
Relative
25.62
2.54
10.09**
78
Nonrelative
1.56
5.28
.30
63
Mean frequency of writing
Total
5.31
1.12
4.76*
80
Relative
9.70
1.58
6.16*
78
Nonrelative
.05
1.35
.04
63
*p < .05.
**p < .005.
***p < .0005.
a
DF = 4.
Note: No significant differences in F levels emerged with physical health as the
controlling health variable.
305


60
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 relo
cation. 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 relation
ship 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 behav
iors 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 satis
faction 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 friend
ship networks, although the operationalization of friendship
is unclear. Interestingly, while ego's satisfaction with


143
The nursing home was the pits. [Ego] got
no care. A nurse never went in the room,
(a wife)
Eg£ls_Feelings about the-Move
Ego's feelings about the move into the ACLF were also
determined by asking the respondent a broad open-ended ques
tion. However, in this instance as ego's feelings were of
central importance ego was considered the primary informant
with alter substitutes made as necessary. Due to
the methodology used (don't knows ranged from n = 2 to
n = 15 for the various categories coded) and the fairly
large number of residents excluded from the analysis due to
their deficient mental status and/or physical health
(n = 30), a large number of alter substitutes were used.
Furthermore, as in the data on the situation before the
move, in some cases alter substitutes were unavailable,
resulting in remaining unknown categories.
Ego shared alter's aversion to nursing home residence.
In all but two cases ego felt better about moving to an ACLF
than to a nursing home. Many residents expressed an intense
desire to avoid nursing home placement at all costs. This
is well demonstrated in such comments as
Convalescent homes are insane asylums.
(a male resident)
When they take me to a nursing home, they can
get a gun. (a male resident)


222
support for the hypothesized supportive, indirect role of
nonrelatives on continued network contact with ego after
ACLF entry.
The relationship between network density and closest
other speaking frequency after ACLF entry is not as clear.
Only relative density has an effect on this variable
(p < .05) Additionally, when total and relative network
variables are regressed on Time 2 contact, nonstandardized
regression coefficients indicate that the effect of density
is consistently greater on Time 2 visiting than on Time 2
speaking for each of the focal networks (see Appendix K,
Table K-3). Again, these findings are explained by the
relative difficulty of phone contact with ego after ACLF
entry, suggesting that network variables have their greatest
effects on the paths of communication with the least resis
tance.
The relationship between reciprocity and closest other
contact frequency is also in the predicted direction; the
higher the degree of reciprocity in ego's network ties
at the time of ACLF entry, the more likely closest other
ties were to endure. The effect of reciprocity on visiting
was demonstrated for all three focal networks, with the
greatest effect emerging for the proportion of reciprocal
links in ego's nonrelative network (see Appendix K,
Table K-3).


Means and standard deviations of the characteristics of new
residents' networks
Network Characteristics Mean SD N
Range
Total personal network
7.36
4.11
81
Relative network
4.60
2.94
81
Nonrelative network
2.83
2.85
81
Density
Total personal network
65.82
22.54
77
Relative network
88.97
15.36
74
Nonrelative network
75.10
25.30
46
Degree
Total personal network
5.05
2.61
77
Relative network
4.59
2.64
74
Nonrelative network
3.68
2.20
46
Number of material linkages
Total personal network
9.65
6.20
81
Relative network
7.22
5.17
81
Nonrelative network
2.46
3.75
81
Range with material linkages
Total personal network
5.59
3.38
81
Relative network
3.90
2.62
81
Nonrelative network
1.83
2.50
81
Number of dependent linkages
Total personal network
3.37
3.74
81
Relative network
2.40
7.79
81
Nonrelative network
1.01
2.11
81
Number of reciprocated linkages
Total personal network
5.21
4.83
81
Relative network
4.06
3.99
81
Nonrelative network
1.35
3.21
81
296


108
While the researcher was able to locate no study that
explicitly examined the directionality of material links in
the networks of vulnerable elderly, several tangential find
ings might help put these results into perspective. Of
these, Wentowski's study on reciprocity and the coping
strategies of nonistitutionalized elderly who still had a
"fair degree of control over their lifestyles" (Wentowski,
1981:602) is probably the most similar in content and pur
pose to the present work. This was a qualitative work,
combining depth interviews and participant observation of 50
older adults. She, too, claims that the norm of reciprocity
is the basis of exchange relationships for her sample.
However, the only data reported (aside from that contained
in three case studies and occasional quotes) are the
percentages of informants reporting kin and non-kin helpers.
Only those kin identified as relatives by marriage were not
commonly involved in helping relationships with the respon
dent. While this indicates a large percentage of ego's
network had at least one material link with ego it does not
substantiate her claim of reciprocity-governed exchange
relationships.
Wellman (1981) examined linkage direction amongst his
sample of East New Yorkers. However, as he reported per
centages of each pattern within each category of supportive
link (i.e., family advice, minor services, major amounts of
money) his analysis is closer in meaning to symmetry than to


Table 11-3:
Variable Name
Focal Network
Total
(N =
Primary
64)
Relative
(N = 61)
Nonrelative
(N = 32)
B
SD
B
SD
B
SD
Location, Time 2
.18
.79
.25
.80
.30*
.83
Marital status
.02
.79
-.02
.75
-.25*
.81
2
R
.40
.41
.72
*P
<
.10.
**p
<

m
o

* *p
<
.01.
* * *p
<
.001
221


Table i-4Continued
Sum of Squares
Physical Mental
Network Characteristics Health Health
Proportion of instrumental
links
Total
Relative
Nonrelative
Proportion of ties perceived
as balanced
Total
Relative
Nonrelative
Mean visiting frequency
Total
Relative
Nonrelative
Mean speaking frequency
Total
Relative
Nonrelative
.14 .05
.12 .12
1.22 1.58
.08 .22
.04 .01
.04 .00
.26 9.27
2.04 18.02
1.24 .24
.20 .51
.26 3.80
3.90 .29
Mean Squares
a
F
Physical Mental Physical Mental
Health Health Health Health N
.02
.03
5.58*
1.94
80
.03
.03
3.71
3.70
78
.62
.62
1.96
2.56
51
.32
.32
.25
.68
79
.16
.16
.23
.08
77
.19
.19
.23
.01
62
3.32
3.20
.08
2.90
80
4.12
3.90
.50
4.62*
78
7.17
7.14
.17
.03
63
2.32
2.31
.08
.22
80
2.59
2.54
.10
1.50
78
5.21
5.28
.75
.05
63
311


84
possible: very good (0), good (1), fair (2), and poor (3).
As self-assessments tend to be influenced by salient refer
ence groups (Ferraro, 1980; Fillenbaum, 1979), it was anti
cipated 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, continence, and
feeding). Grading of the scale is as follows (Katz et al.
1963:915):
A. independent in feeding, continence,
transferring, going to toilet, dressing,
and bathing;
B. independent in all but one of these
functions;
C. independent in all but bathing and one
additional function;
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
additional function;
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


182
with a sense of comfort and satisfaction knowing that ego
was being well taken care of. Both of these conditions were
said to be facilitated by the fact that ego's ACLF residence
was convenient to alter's work or home, which eased regular
visits with ego. Evidence for their perceived lifestyle
improvement is found in the following statements:
This gives me much more freedom. I feel safe
because she's under care. It gives me
satisfaction that she is being taken care
of. (a husband of a resident)
The ACLF is scheduled around themI wasn't.
It's worked out really well. (a daughter-in-law)
She's almost like she was at our house. She's
so close I can stop by and see her almost every
night after work. (a son)
The mental relief is fantastic. But ego's
money is running out. What then? (a daughter-
in-law)
Up until the move there was something going on
all the time. It's an answer to our prayers.
(a daughter-in-law).
While an improvement in alter's lifestyle had been
anticipated by the researcher, the large number of signifi
cant others identifying no lifestyle change was not antici
pated. When alter was asked to elaborate on this response,
the predominant theme was one of continued responsibility on
the part of alter for ego. Unlike nursing homes, the ACLF
was not a "one-stop" medical facility for ego. Thus, alter
was still responsible for orchestrating ego's medical needs.
This situation is demonstrated in the following responses:


294
NETWORK CHART
18a. Name *
*
*
is
18b. Tie basis *
*
*
*
18c. Seen *
*
*
*
18d. Spoken with *
*
*
*
18e. Letters *
*
*
*
18f. Receives money *
*
*
*
18g. Receives help *
*
*
*
18h. Receives gifts *
*
*
*
18i. Provides money *
*
*
*
18j. Provides help *
*
*
*
18k. Provides gifts *
*
*
*


26 9
111.
Keeps
feelings *
*
*
*
12.
Feels
balanced *
*
*
*


121
Yet, the trends revealed for the total network remained.
Thus, the network structure of nonwhites was "glued" to
gether more tightly, facilitating greater support for ego,
the possibility of greater normative pressure for this sup
port, and a greater potential for the network of nonwhites
to maintain their relationship with ego despite ego's move.
The "strength of the glue" may be a causal factor in
the significantly higher network emotional bondedness to ego
for nonwhites than for whites. This relationship was sig
nificant for the total primary network (p < .001) and for
the relative (p < .005) and nonrelative subsectors
(p < .05). Another explanation for the apparently higher
degree of emotional bondedness of nonwhites to their network
may be found in the work of Creecy and Wright (1979). While
the researcher attempted to minimize any perceptual differ
ences related to friendship by different individuals or
social groups by using the Emotional Bondedness Question
naire (Snow and Crapo, 1982), it is possible that these
potential differences carried over to the way ego inter
preted the elements of the researcher's questions. This
could have resulted in a tendency for nonwhites to answer
more favorably in regard to their primary network relation
ships.
Whites and nonwhites also differed in the manner in
which they stayed in contact with each other. While no


158
health. Only the density of the relative sector explained
ego's presenting self-care ability (p < .05). These findings
also suggest that it is the structure of ego's total primary
network rather than the structure of either of the
subsectors of this primary network that has a critical
effect on the process of ACLF entry.
Furthermore, when the effects of the other character
istics of ego's total network are compared to the effect of
density on ego's presenting health status, results indicate
that all of the interactional characteristics have a much
lower explanatory power (see Table 9-1). Thus, the impor
tance of total network density on delaying ego's ACLF entry
is further underscored, suggesting, as do the findings of
Sokolovsky et al. (1978:14) that "persons with small, poorly
connected networks represent an at-risk group requiring
added professional support if they are to remain out of an
[institution]."
Reasons for these findings are multiple. As the
analysis of the effect of connectivity on the labeling and
referral process failed to take into account the
connectivity of the network of ego's closest other, it can
only be speculated that the effect of density on ego's
presenting health status is due in part to differences in
information for problem recognition and help seeking.
Support for this hypothesis must wait for future study.


216
Closest Other Contact Frequency
The focus of the analysis of closest other contact
frequency was on the relationship of total primary and
relative and nonrelative subsector network variables to
ego's visiting and speaking contact with his/her closest
other after ACLF entry. It was hypothesized that closest
other tie duration would also be directly related to the
density, degree, intensity, and reciprocity of ego's network
ties net of the pattern of closest other visiting and
speaking prior to the move into the ACLF. Thus, as with the
analysis of network tie duration, Time 1 levels of speaking
and visiting were controlled for by utilizing a multiple
regression analysis and entering them in the equation as the
first independent variables. As before, controls were added
for sex, race, socioeconomic status, physical health, and
mental health. The additional control of marital status
(married was coded 0 and nonmarried coded 1) was also in
cluded for this analysis.
In addition to explaining total primary and relative
tie duration, the network variables density and reciprocity
are also positively related to closest other contact fre
quency. However, in this analysis only the objective indi
cator of reciprocity was a useful explanatory variable.
Perceived balance was not significant. The effects of in
tensity and degree on contact frequency at time two were
also not significant (p > .05) While none of the controls


APPENDIX K
VARIABLE EFFECTS ON
RETURNING HOME AND TIE DURATION


123
reason for finding a significant relationship with race and
perceived balance can only be speculative, two plausible
explanations are offered. First, this finding may be due to
the more inclusive nature of the perceived measure. While
the objective measure addressed only material links, the
perceived measure included both material and nonmaterial
links between the network and ego. Thus, the strong posi
tive association between nonwhites and network emotional
bondedness may carry over to result in an overall feeling of
an even give and take between ego and his or her network.
Secondly, as the perceived measure was obtained in response
to a direct question to the believed sense of balance in a
network relationship any "no" responses would be more ap
parently in conflict with the norm of reciprocity. This may
be adhered to more strongly by nonwhites than by whites.
Hence, there would be less likelihood for a negative re
sponse by nonwhites.
acioecononiic Differences
As might have been expected, money did make a differ
ence. Controlling for sex, race, and health (both physical
and mental), both the objective and perceived measures of
network tie directionality, the size of ego's nonrelative
network with at least one material link to ego, and the mean
network emotional bondedness to ego varied significantly
with socioeconomic status. However, there was no


64
related to his/her length of hospitalization. Neither meas
ures of dangerousness nor standardized symptomatology meas
ures were significant length of stay predictors. Interest
ingly, 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
primary network.
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
ACLF entry;
c. the likelihood of ego's problem being labeled
by a professional; and


285
NETWORK CHART
17a. Name *
*
*
*
17b. Tie basis *
*
*
*
17c. Seen *
*
*
*
17d. Spoken with *
*
*
*
17e. Letters *
*
*
*
17f. Receives money *
*
*
*
17g. Receives help *
*
*
*
17h. Receives gifts *
*
*
*
17i. Provides money *
*
*
*
17j. Provides help *
*
*
*
17k. Provides gifts *
*
*
*


135
this source. While the function of nonrelative primary
network members was relatively rare in terms of labeling, a
larger percentage identified them as the source of ACLF
referral.
Possibly the most interesting finding in terms of the
informal network is the fairly small percentage of respon
dents who identified ego as the one who determined that
he/she no longer "fit in." Given the profound consequence
of having to move out of one's home or current place of
residence (which is likely to occur with the imputation of
this label) perhaps it is not surprising that the elderly
are reluctant to attribute this type of deviance to them
selves.
Ego's role was even smaller when it came to identifying
an ACLF as a relocation site, with only 4.9% of the respon
dents attributing this function to ego. Thus, unlike in the
findings of Tobin and Lieberman (1976), ego's role in this
process was found to be secondary to that of key others,
with the importance of relatives predominating.
This difference in findings may be explained, at least
in part, by this researcher's more inclusive sample. Tobin
and Lieberman (1976) systematically exlcuded those too phy
sically or mentally frail to be interviewed. It is this
group which is most likely to be orchestrated into a


288
Special Section
Hello, my name is Mary Bear. I visited you
approximately six months ago in regards to my study for the
University of Florida on the process by which an older
person comes to move into an ACLF. Now I am finishing up my
study and would like to stop by and see how ego is doing.
However, I was not able to find ego at (insert name of
original ACLF). Could you please tell me where ego is
currently living?
Current address
If ego has died, prior to his/her death, did ego
(0)
Remain
at the original ACLF
(1)
Return
to his/her home
(2)
Go to
the home of a friend/relative
(3)
Go to
a nursing home
(4)
Go to
a hospital
(5)
Other
Arrange for a time to call ego's significant other back if
necessary after visiting with ego.
Call back time
(When significant other is called back, return to
informed consent section of questionnaire on first page.)


Table 11-4. Variable effects on ego's Time 2
regression coefficients
network
material linkages,
standardized
Total
Network
(N = 62)
Relative
Network
(N = 60)
Nonrelative
Network
(N = 31)
Variable Name
B
SD
B SD
B
SD
Material links, Time 1
.39***
.12
.29** .12
.25
.20
Density, Time 1
.22*
.00
.19* .00
.14
.01
Closest other intensity,
Time 1 -.21
.03
-.01 .03
-.05
.06
Network bondedness, Time
1 .08
.03
-.22 .02
.06
.05
Reciprocity"objective,
" Time 1 .08
.26
.07 .30
.09
.29
Sex
-.11
.15
.10 .14
-.09
.28
Race
-.32**
.23
-.31** .23
-.22
.47
SES
.17
.20
-.07 .21
.54**
.38
Mental health, Time 2
-.08
.06
-.08 .05
-.18
.11
Location, Time 2
-.29*
.25
-.10 .27
-.31
.50
R2
.41
.35
.45
*p < .10.
**p < .05.
***p < .001.
229


CHAPTER THREE
NETWORK VARIABLES AND ACLF RELOCATION
Labeling and Referral
Relocation into an ACLF is the outcome of an inter
active process. Through interaction with others the behav
ior 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 in
crease in their dependency as a result of recognized physi
cal 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 cen
tral importance.
The initial redefinition or labeling of behavior may be
imputed by the potential ACLF resident, a key network mem
ber, 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.
27


17
meaning is culturally and hence situationally bounded, mor
phological 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 ego, 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 net
work. 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 analyz-
able a network must be delimited. In addition to anchorage,
other methods of network delineation include content speci
fication 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


67
Referral by a professional
Density and
degree
Figure 4-1. Hypothesized effects of network variables
on ACLF relocation


93
Due to the age of the respondents, and the large per
centage of respondents that mentioned a relative as his/her
"closest other," there was typically a very high duration of
the relationship between ego and alter. The median duration
was 40 years, with an upper quartile beginning at 50 years,
and a lower quartile beginning at 21 years.
Furthermore, when duration was regressed on ego's age
and kinship with the significant other, highly significant
direct relationships were demonstrated (p < .001) Thus, in
effect, for this population duration indicated the age of
the respondent, and hence, the age of his/her closest other,
along with ego's kinship with alter, rather than the inten
sity of the relationship. Duration was, therefore, deleted
from the subcomponents of the intensity construct, reducing
the potential range of scores to from 6 to 18.
The contaminating effects of age and kinship on dur
ation were also recognized in the work of Marsden and
Campbell (1984). Additionally, they found that frequency of
contact via visiting was complicated by neighboring. Net of
strength, neighbors tended to see each other more often than
non-neighbors.
This same complication appeared in this study, only in
a slightly different form. Frequency visiting was skewed to
the right due to the high percentage of new residents who
had lived with their closest other prior to their move into
the ACLF, and hence visited him/her daily. However, as


234
and Directions. fQE-future Research
Network variables were demonstrated to influence the
process by which the elderly came to enter the ACLF, the
degree to which they settled into this new environment, and
the degree to which the ties residents had with their pri
mary network before they entered into the ACLF endured.
Additionally, ego's race, socioeconomic status, and health
were also significant in explaining these processes.
Entering the ACLF
Entering the ACLF required both that ego's current
environmental fit be recognized as problematic and that
moving into an ACLF be determined an appropriate response.
Professionals played only a secondary role in these deci
sions. The elderly's informal network, more specifically,
relative primary group members were the principal source of
problem recognition and ACLF referral.
While it had been hypothesized that the involvement of
either professionals or informal network members in the
labeling and referral process would be a function of the
density and degree of the elderly's personal network, this
was not supported. An explanation is found in the inappro
priate choice of anchors for network delimitation. As ego's
relatives primarily made these decisions, with ego only
rarely responsible for self-labeling or referral, the


157
Ego's Presenting Health Status
It was hypothesized that the severity of ego's health
at the time of the move into the ACLF would be directly
related to the density, degree, reciprocity, and intensity
of ego's network ties. Additionally, the intensity of the
relationship with ego's closest other was also predicted to
be directly related to the severity of ego's mental and
physical health at the time of the move.
While the effect of the independent variables differed
by focal network and the health indicator (with the model
generally explaining a higher proportion of the variance in
ego's presenting mental than physical health) density,
degree and closest other intensity were all found to be
significantly related to ego's health at the time of the
move (see Appendix J, Tables J-3 and J-4). The controls
sex, race, and socioeconomic statushad no effect.
Additionally, controlling for ego's sex, race, and socio
economic status, there was no relationship between the
severity of ego's presenting health status and the source of
ego's label or referral.
The density of ego's total network was directly related
to both the severity of ego's mental health (p < .001) and
to ego's level of dependence in the activities of daily
living (p < .05) at the time of the move. However, when the
relative and nonrelative sectors were considered, the
density of these sectors was not related to ego's mental


215
Nonwhites were in more frequent visiting and speaking con
tact with relatives and more frequent speaking contact with
their total primary network prior to their move. However,
after ACLF entry, the effect of race became generally in
significant, with nonwhites tending to be in less frequent
visiting and speaking contact with ego. This suggests, as
does Mutran's study (1985), the difficulty of separating the
effects of culture from social structure.
Similarly, while males had been in more frequent
visiting contact with their total primary network and in
more frequent visiting and speaking contact with their rela
tive subsector prior to ACLF entry, after their move these
differences were no longer significant. In terms of ego's
mental health, prior to ACLF entry poorer mental health was
associated with less written contact with ego's total per
sonal network and with his/her relative subsector, and a
greater number of visits with relatives. After the move,
there was no longer any difference in network written com
munication or in frequency of relative visits and speaking
contact with ego's total primary network became negatively
related to ego's mental health (p < .05). Thus, it seems
that the structural barriers associated with ACLF entry were
more limiting on network contact with ego for nonwhites and
males, and for the networks of residents with a poorer
mental health status.


210
Similarly, nonstandardized regression coefficients in
dicate that, while density explains both Time 2 total and
relative visiting and speaking, its influence on visiting is
consistently greater (see Appendix K, Table K-2). This may
be understood by reviewing the findings in Chapter Ten on
the structural barriers imposed by the ACLF and the effect
of ego's declining health on telephone utilization by resi
dents and their networks. It seems that negative effects of
the place also act to limit the speaking tie duration moti
vating force of network density, resulting in finding den
sity to have a lesser effect on Time 2 speaking than
visiting contact between ego and network members after ACLF
entry.
The fact that density and not degree explained tie
duration after ACLF (see Appendix K, Table K-2) entry led
this researcher to focus her analysis on the regression
equations with density as the connectivity indicator. This
finding reinforces the difference between these two indica
tors of network connectivity which has been demonstrated
throughout this dissertation. While density is the propor
tion of theoretically possible linksand thus reflects the
tightness of fit in a network, degree is the average number
of relationships networks have with each other, thereby
reflecting more of a scope dimension of connectivity.
Based on these results, one would say that the
tightness of fit of one's network rather than the magnitude


Table 1-2Continued
a
Network Characteristics
Sum of Squares
Mean Square
F
N
Bondedness of significant other to ego
.09
35.33
.00
74
Proportion of reciprocated links
Total
.13
.07
1.80
80
Relative
.13
.08
1.75
78
Nonrelative
.03
.20
.15
51
Proportion of dependent links
Total
.27
.09
3.00
80
Relative
.15
.09
1.60
78
Nonrelative
.10
.21
.49
51
Proportion of independent links
Total
.04
.03
1.39
80
Relative
.00
.03
.02
78
Nonrelative
.03
.62
.05
51
Proportion of ties perceived as balance
Total
3.15
.32
9.88**
79
Relative
.26
.16
1.67
77
Nonrelative
.04
.19
.19
62
Mean frequency of visiting
Total
4.78
3.20
1.50
80
Relative
20.30
3.90
5.20*
78
Nonrelative
.80
7.19
.11
63
304


APPENDIX A
EMOTIONAL BONDEDNESS- SCALE


137
indicate that while physicians are not very involved in
entry into an ACLF, they are involved in the process of
institutionalizing the frail elderly. If this is indeed the
case, it would be interesting to determine the basis for
this differential referral pattern.
The Situation before the Move
Once again, due to the importance of ego's informal
network in the relocation process, alter was considered as
the primary informational source with substitutes from ego
used only when alter responses were missing. However, un
like the data on labeling and referral, this information was
obtained from compiling answers to a broad, open-ended ques
tion and there is a greater incidence of missing data among
alter responses (don't knows ranged from n = 0 to n = 15 for
the various categories coded). This resulted in more ego
substitutions as data sources than in the data obtained from
fixed response questioning. As ego substitutes were not
always available some don't know responses remained.
This researcher lends support to the contention that
relocation of the elderly to a nursing home or ACLF is
generally done only after all other perceived alternatives
have failed (Brody, 1977; Habenstein, Kiefer, and Wang,
1976; Hilker, 1983; Lowenthal-Fiske, 1964; Shanas, 1979;
Tobin and Lieberman, 1976). In all but 5% of the cases, ego
was already dependent upon somebody else for help (see Table


24
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 recip
rocity played in relationships was normative, "something
received requires something returned" (1981:602-603). Re
turn 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, inten
sity may be understood as an indication of the strength of a
particular link. Yet from that point one finds much dis
agreement 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 de
gree of interpersonal "closeness" and interactional fre
quency. 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 no
tion of intensity, positing that intense or effective rela
tionships are many "stranded" or multiplex. Wheeldon goes


282
12. Which of the following best describes your current
living condition?
(0) I am living alone without any help
(1) I am living alone with the help of my
family and friends
(2) I am living alone with the help of formal
agencies
(3) I am living alone with the help of family
and friends and formal agencies
(4) I am living with family/friends
(5) I am living with family and friends and
being helped by formal agencies
(6) I am in a nursing home
(7) I am in a hospital, but plan to return
to an ACLF
(8) I am in a hospital and don't plan to return
to an ACLF
(9) I am in the same ACLF
(10)I am in a new ACLF
13. Which of the following best describes your current
"fit" with your living situation?
(0) Very good
(1) Good
(2) Fair
(3) Poor
14. At this time how would you describe your overall
health?
15. Since I first saw you, would you say that your overall
health has
(0) Improved greatly
(1) Improved slightly
(2) Stayed the same
(3) Declined slightly
(4) Declined greatly
16. Since I first spoke with you, would you say that your
lifestyle has
(0) Improved greatly
(1) Improved slightly
(2) Stayed the same
(3) Declined slightly
(4) Declined greatly


171
compensated by maintaining a larger relative network. There
was no significant difference in the size of the relative
networks between these groups. This finding runs somewhat
counter to Cantor (1979) who found a more active friendship
network among those without nearby children.
In conclusion, network variables were found to be re
lated to the ACLF relocation process in four ways. First,
the degree to which ego is emotionally bonded to his/her
total personal network was directly related to the prob
ability of ego being professionally labeled as "out of
place." Second, while the connectivity of ego's network did
not influence the source of ego's "out of place" label or
ACLF referral an explanation for this may be sought in the
characteristics of ego's closest other's network, as a mem
ber of ego's informal network was primarily responsible for
orchestrating ego's move. Third, having a primary network
with less than two members other than ego increased the
likelihood of ego's condition being both formally labeled
and formally referred; and having less than two close rela
tives increased the likelihood of ego's condition being for
mally referred only. And, fourth, ego's presenting health
status is directly related to the density of ego's primary
network, the intensity of ego's relationship with his/her
closest other, and the degree of ego's nonrelative network.
In terms of the control variables, while neither sex,
race, nor socioeconomic status had any effect on ego's


268
NETWORK CHART
10a. Name
*
*
*
*
10b. Tie basis
*
*
*
*
10c. How long known
*
*
*
*
lOd. Seen
*
*
*
*
lOe. Spoken with
*
*
*
*
lOf. Letters
*
*
*
*
lOg. Receives money
*
*
*
*
lOh. Receives help
*
*
*
*
lOi. Receives gifts
*
*
*
*
10j. Provides money
*
*
*
*
10k. Provides help
*
*
*
*
101. Provides gifts
*
*
*
*
11a. Counts on
*
*
*
*
lib. Angry
*
*
*
*
11c. Sensitive
*
*
*
*
lid. Listens
*
*
*
*
lie. Hurts feelings
*
*
*
*
Ilf. Thinks highly
*
*
*
*
llg. Discourages
*
*
*
*
llh. Cheers up
*
*
*
*
Hi. Eye to eye
*
*
*
*
11j. Trouble
*
*
*
*
Ilk. Enjoys time
*
*
*
*


APPENDIX G
FOLLOW-UP QUESTIONNAIRE
ADDRESSED TO RESIDENT'S CLOSEST OTHER


118
However, when the relative and nonrelative subsectors
were analyzed separately, this relationship disappeared.
There was no significant difference by sex. This means that
among only ego's relatives, and among only ego's close
nonrelative ties there was no difference between males and
females in the proportion of links actualized. But, when
these important groups were combined the internetwork link
ages were greater for men. If density is indeed a support
ive resource, this may be a critical between-sex network
difference.
Positing an explanation for this relationship in the
differential marital states of the sample's males and fe
males, a control for this variable was added. No spurious
relationship was revealed. Marital status was not signifi
cantly related to ego's total personal network density, and
the association between sex and network density remained
significant (p < .01).
The size of ego's network was only different by sex
when analyzing ego's total personal network controlling for
ego's physical health (p < .05). However, there was a
consistent tendency for the networks of females to be larger
than that of males.
In terms of the interactional variable, contact fre
quency, while there was no significant difference in the
mean frequency of written communication between ego and


V
CHAPTER EIGHT
THE PROCESS OF INSTITUTIONALIZATION
Data on the process by which ego was labeled "out of
place" and referred were obtained from both ego and alter,
allowing the researcher to note any perceptual differences
from the different sources of "the truth." Unlike the
comparison of paired ego and alter network data, in this
case ego's and alter's perception of the process ACLF entry
was significantly different. Ego was more likely to identi
fy a formal network member as the source of the label and
alter was more likely to attribute this function to an
informal network member (p < .05). A similar tendency was
revealed for ACLF referral (p < .10). Ego once again was
more likely than alter to attribute this function to a
professional. However, there was no significant difference
between ego's and alter's perception of the source of ego's
ACLF payment.
While these perceptual differences may be attributed to
the blame dispersion tactics used by ego's informal network
that are discussed later in this chapter, for the purpose of
data analysis it was decided to consider alter as the
preferred source of "the truth" as both ego and alter iden
tified ego's primary network as the one usually responsible
132


267
17. List each of ego's network members in a random pattern
on a blank sheet of paper. Assist the respondent in
connecting each of these members who are currently in
fairly regular contact with each other. Identify the
relationship to ego as relative (R) or nonrelative (NR).
A sample response is illustrated below.
r Ego
Helen(NR
Landon(R
Aria(R)
Erma (R)
Trudi(NR) -
Lorraine(R)
Jack(R)
Marvin(R)
Sue(R)
all connected
to each other
Total N = 10
Total Na = 36
Total Density = 80%
Total Degree =7.2
Relative
Relative
Relative
Relative
N = 8
Na = 26
Density = 92.9%
Degree = 6.5%
Nonrelative N = 3
Nonrelative Na = 2
Nonrelative Density = 66.7%
Nonrelative Degree =1.3


35
Furthermore, as discussed by Hammer (1963:244), a dense
network structure facilitates intranetwork support for mem
bers struggling to maintain ego in his/her current living
situation. In essence, "the effects of the patient's behav
ior may be shared, thus creating less pressure for the
severance of ties." Density also plays a role in the pres
sure 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 pat
terns.
Tie Duration
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


253
status is unavoidable with ACLF entry, efforts should be
directed at allowing ego to continue to do for others. To
this end, staff assistance with letter writing, gift pur
chases, or outgoing telephone calls would be helpful. For
instance, residents may be able to provide supportive tele
phone calls to friends struggling to remain at home, which
would maintain ties, build resident self-esteem, and help
delay institutionalization for an at-risk group of elderly.
In conclusion, as the long-term care needs of our
rapidly aging population place increasingly heavy demands on
our nation's already strained health budget, continual anal
ysis of our response to the health needs of the elderly is
prudent. Along these lines, alternatives that reduce the
cost of care without sacrificing its effectiveness must be
explored. Adult Congregate Living Facilities are one such
alternative. This researcher contributes to this need by
examining the process by which the elderly are relocated in
ACLFs. It should provide both health providers and re
searchers with more information regarding the relationship
between social networks and health care utilization. More
over, it contributes necessary descriptive information about
the nature of the ACLF population and their networks. Thus,
this study provides information useful toward the effective
and efficient expenditure of our health dollar, as well as
contributing to the knowledge base of network analysis.


249
of these structures must minimize accompanying bureaucratic
elements.
Strategies to Improve ACLF Caring
This researcher has demonstrated that two problematic
consequences of ACLF entry are decreased frequency of con
tact with network members and decreased network material
linkages with ego. As persons in ego's informal network are
key sources of material and nonmaterial linkages with ego
(see Chapter Six), moves to counter this situation are
indicated. Furthermore, as was demonstrated by Arling,
Hawkins, and Capitman (1986), and Ryden (1984, 1985), main
taining social contacts is also related to one's sense of
personal control. Working to maintain these contacts may
act to counter the decrease in personal control and stress
that is experienced by some of the elderly with ACLF entry.
As decreased tie contact is explained by the char
acteristics of ego's network, and by the structure of ACLFs,
a dual intervention strategy is suggested. Both a network
intervention strategy and an effort to decrease contact
barriers secondary to moving into an ACLF should be
attempted. However, as a key positive feature of ACLFs is
their noninstitutionalized character, it is important that
in implementing both of these strategies one works within
the ACLF as much as possible, minimizing the potential for
increasing its bureaucratic flavor.


224
emphasize the difficulty of maintaining phone contact with
ego after ACLF entry.
The lack of significance of perceived balance on clos
est other visiting and speaking frequencies is consistent
with the findings in the analysis of the frequency of net
work contact patterns. Only written contact was explained
by perceived balance; speaking and visiting were not. As
discussed earlier, it is not surprising that these two
indicators differentially explain tie duration. While sub
jective reciprocity includes both emotional and material
dimensions, "objective" reciprocity only takes into account
the material give and take balance. These findings, then,
coupled with finding that neither the intensity of ego's
closest other relationship nor the intensity of ego's net
work relationships explained closest other contact frequency
indicate that the balance of material links has a greater
effect on tie duration after ACLF entry than does the inten
sity of emotional relationships.
In terms of the control variables, the effect of race
(p < .05) and marital status (p < .10) was limited to the
analysis of nonrelative network variables. This is a select
subsample of the study (N = 32). Thus, only for those new
residents with at least two nonrelative close others do race
and marital status make a difference on Time 2 contact, with
Time 2 closest other contact greater if ego is nonwhite and
married. In this case nonwhites are able to overcome any


CHAPTER TEN
THE PARTICIPANTS:
THE RESIDENTS SIX MONTHS LATER
As noted in Chapter Five, an alternative strategy was
used for data collection at Time 2. As the resident was the
one "closest to" the information sought at follow-up, ego
was considered the primary informant. Thus, 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 of town location (n = 3), or if
the family preferred that the researcher contact them
instead of ego (n = 2). In these instances, alter's
responses were then substituted for ego's.
This strategy resulted in the high follow-up completion
rate of 88%. Six (7.4%) of the residents had died within
this six-month period, reducing the sample size to 75. Data
on only four (5%) of the surviving respondents were in a
large part unavailable at Time 2 due to respondent refusal,
or information gaps on the part of alter.
Place of Residence
The researcher found that the ACLF population is highly
transient. Slightly less than two-thirds of the residents
interviewed at Time 1 were at the same place of residence
174


31
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 le
gitimate) In making this distinction Freidson refined
Parsons' notion of illness behavior (1968). While Parsons
believed that the imputation of all types of illness behav
ior carried the obligation for the "imputee" to pursue a
return to a healthy status, Freidson stated that only ill
nesses judged to be acute carried this expectation.
Thus, acute illnesses are conditionally legitimate,
with the "imputees" being excused from their social obliga
tions 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 defini
tion, 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 reac
tions, thus, are relatively unconditional on self-efforts to
return to a healthier state. Therefore, while states im
puted as chronic do carry future role definitions, acute
conditions are much more temporary in duration.


CHAPTER NINE
NETWORK VARIABLES AS PREDICTORS OF ACLF ENTRY
Each of the network variablesreciprocity, density,
degree, and intensitywere analyzed to determine if their
hypothesized effects on the process of ACLF relocation had
occurred. To determine the differential effects of the
focal networks, the analysis determined the effect of these
variables as defined by both ego's total primary network and
relative and nonrelative subsectors. Additionally, the sub
jective and objective reciprocity measures, as well as the
dual connectivity measuresdensity and degreewere
analyzed separately to minimize the problem of multicol-
linearity.
As density and degree can only be computed for networks
with at least three members (including ego), residents with
zero or one network member in addition to themselves were
excluded from the analysis. This only excluded 4 residents
from the total network analysis, and 7 from the relative
network analysis. However, 43 observations were excluded
from the nonrelative network analysis. A separate analysis
of these network deficient residents is found at the end of
this chapter.
The focal dependent variables at time 1 were the source
of ego's labeling and referral and the severity of ego's
146


298
Appendix HCflufcirmgd
Network Characteristics
Mean
SD
N
Mean emotional bondedness
Total personal network
32.10
3.23
80
Relative network
31.31
4.13
78
Nonrelative network
33.09
3.14
63


316
Table J-2. Variable effects on the log odds of formal
versus informal referral to an ACLF by
connectivity measure and focal network
Connectivity
Measure
Focal Network
Total
(N =
Primary
77)
Relative
(N = 74)
Nonrelative
(N = 46)
Logit
SD
Logit
SD
Logit
SD
Density
-.01
.01
.01
.02
.00
.01
Race
.87
.75
.59
.82
.16
.94
SES
.86
.70
1.00
.74
1.63*
.87
Sex
-.83
.61
-.49
.57
-.58
.76
Degree
-.13
.11
-.24
.15
-.18
.18
Race
.95
.78
1.21
.87
.51
.96
SES
.91
.70
.79
.76
1.79**
.91
Sex
-.66
.57
-.42
.58
-.61
.75
*p < .10
**p < .05


11
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 ques
tions and incorporated standardized measurement tools.
The theoretical basis for this dissertation is pre
sented in the second and third chapters. Chapter Two dis
cusses 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 1, and
Chapters Ten and Eleven analyze the results of the informa
tion collected at Time 2. Finally, a discussion of the
theoretical and practical implications of this dissertation
is outlined in Chapter Twelve.


148
with males, whites, and private residents coded 0 and
females, nonwhites, and state paying residents coded 1.
Additional analyses were done to determine if any rela
tionships between the dependent variablesego's health, the
source of ego's label, and the source of ego's referral
existed.
Labeling
It was hypothesized that the probability of ego's con
dition being labeled by a professional would be directly
related to the density, degree, reciprocity, and intensity
of ego's network ties. Additionally, due to the proposed
importance of ego's relationship with his/her closest other,
the effect of the intensity of this bond on the labeling
process was hypothesized as a separate variable directly
related to the probability of professional labeling.
While the controls of sex and race had no effect on the
labeling process, ego's socioeconomic status did explain the
source of ego's "out of place" label. The state-financed
resident was more likely to have been professionally labeled
than the private payer (p < .05) This finding was only
significant when the effect of ego's total primary network
on the labeling process was being analyzed. However, the
trends remained for the subsector analysis. This means that
when the state is paying for ego's ACLF care, a professional
is more likely to have labeled ego as being "out of place"


161
these networks would then limit network degree. Thus, while
network density varies directly with the severity of ego's
health status, an inverse relationship tends to exist
between ego's presenting health severity level and degree.
One exception to this unanticipated trend was found.
The degree of ego's nonrelative network was directly related
to ego's level of dependence in activities of daily living
(p < .05) This result is congruent with the hypothesized
relationship between ego's health and degree. The higher
the degree of ego's nonrelative network, the lower ego's
presenting self-care level. Thus, in spite of the fact that
frail residents tended to have less members in their non-
relative sectors, these nonrelative networks members had a
higher average number of intranetwork relationships than
those who were less physically frail at the time of their
move.
The positive relationship between reciprocity and ego's
presenting health severity level was not confirmed. There
was a trend in this direction, but this was only with ego's
presenting mental health status and the proportion of reci
procated links in ego's total primary network (p < .10).
Subjective reciprocity tended to decrease as ego's
presenting mental health status worsened, and in terms of
ego's physical health no consistent relationship emerged
with either linkage directionality measure.


Table K-3Continued
Focal Network
Relative (N = 61)
Closest other visiting, Time 1
Closest other speaking, Time 1
Density, Time 1
Degree, Time 1
Closest other intensity, Time 1
Network bondedness, Time 1
Reciprocity--"objective," Time 1
Reciprocity--"subjective," Time 1
Sex
Race
SES
Mental health, Time 2
Physical health, Time 2
Location, Time 2
Marital status
2
R
Percentage of variance by Time 1 contact
Net percentage of variance
Type of Contact
Closest Other Closest Other
Visiting, Time 2 Speaking, Time 2
b SD
b SD
46*****
.14


--

.55****
.20
0 4***
.01
.02**
.01
03
.12
.07
.11
01
.13
-.04
.12
06
.07
-.02
.06
69**
.92
.51
.86
60
.69
. 86
.60
05
.47
.26
.43
04
.77
-.33
.70
91
.68
-.51
.62
13
.19
-.16
.17
16
.12
-.13
.11
35*
.80
.57
.74
10
.75
-.20
.68
41
.27
23
.18
18
.09
330


Table K-l. Variable effects on staying in an institution
by connectivity measure and focal network
Focal Network
Total Primary Relative
(N = 70)
(N =
69)
Connectivity
Measure
Logit
SD
Logit
SD
Density, Time 1
.03
.03
.02
.04
Sex
-.06
1.17
-.34
.98
SES
3.66**
1.86
2.19
1.37
Race
-4.39**
1.90
-2.89*
1.52
Physical health,
Time 2
2.48**
1.14
2.49**
1.10
Network bondedness,
Time 1
.37**
.18
.15
.11
Closest other
intensity, Time 1
.04
.17
.14
.18
Reciprocity
"objective," Time la
1.19
1.89
.78
1.84
Reciprocity
"subjective," Time 1
.07
1.27
-1.07
1.29
Degree, Time 1
-.14
.14
-.13
.13
Sex
-1.10
1.04
-.70
.95
SES
3.02*
1.63
2.07
1.39
Race
3.61**
1.60
-2.52*
1.43
Physical health,
Time 2
2.36**
1.08
2.47**
1.09
322


Table K-3Continued
Type
of Contact
Closest
Visiting,
Other
Time 2
Closest
Speaking,
Other
Time 2
Focal
Network
b
SD
b
SD
Net
percentage of variance
.44
.46
*p < .10.
**p < .05.
***p < .01.
****p < .005.
*****p < .001.
a
While this table includes both connectivity, reciprocity, and health measures, they were
regressed on Time 2 closest other contact frequency separately. The reported
coefficients of the remaining variables and summary measures are from the regressions of
density, objective reciprocity, and mental health.
332


212
reciprocated links was positively related to relative
visiting (p < .05) and to nonrelative writing at Time 2
(p < .01). However, there was a tendency for the proportion
of relative reciprocated links, to vary inversely with the
frequency of relative writing at Time 2.
The effect of reciprocity indicates that the more ego
was able to maintain a balanced give and take relationship
with relatives prior to ACLF entry, the higher was the
frequency of relative visiting after ACLF entry occurred.
Possibly, as has been theorized by Gouldner (1960) Horowitz
and Shindelman (1983), and Wentowski (1981), these relatives
were less likely to feel like they had already done more
than their fair share. Hence, they expended the required
effort to maintain visiting contact with ego after ACLF
entry. Alternatively, the past efforts of ego toward net
work members may act to obligate network members to continue
to "do for" ego by maintaining contact with him/her. Sim
ilarly, while visiting and speaking contact by nonrelative
close others may be prohibitively difficult, continued writ
ten contact by this subnetwork may be facilitated by the
fact that up to the time of ACLF entry, ego had maintained a
relatively balanced relationship with them. However, it
should be noted that although this may be the easiest way
for nonrelatives to stay in contact with ego, its frequency
of use is low (see Chapter Ten).


APPENDIX E
INITIAL QUESTIONNAIRE
ADDRESSED TO RESIDENT'S CLOSEST OTHER


FOLLOW-UP QUESTIONNAIRE
ADDRESSED TO RESIDENT'S CLOSEST OTHER
Hello, my name is Mary Bear. I visited you
approximately six months ago in regards to my study for the
University of Florida on the process by which an older
person comes to move into an ACLF. Now I am finishing up
my study and am calling to ask you some questions about how
ego* (substitute name of resident for ego throughout the
questionnaire) is doing at this time. I am also interested
in learning about how ego's move into the ACLF has affected
his/her family and friendship relationships. My questions
will take approximately one-half hour, and, as before, all
answers will be confidential.
1. Is this a good time to ask you some questions?
Yes No [If no, arrange a time to call
back. If yes, obtain permission to proceed with
questionnaire. Go to (9) if ego has not moved;
otherwise, start at (2).]
Informed consent obtained not obtained
Date of follow-up interview
Resident's name
Score from Katz Activities of Daily Living
Questionnaire
(obtained from caregiver at ACLF)
Score from Short Portable Mental Status Questionnaire
(obtained after questioning ego)
Complete after researcher has done a mental and physical
assessment on ego and ego has been deemed incompetent. If
ego is no longer at the original ACLF and caregiver was
unable to provide information on ego's current residence,
begin with Special Section.
287


3
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 na
tional 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 Statistics, 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 = 1,552)
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 regu
larly (Cantor, 1979). Furthermore, even when children are
available, as the elderly continue to age, one is


37
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 posi
tive. As outlined by Hammer (1963) and Hammer and Shaffer
(1975), there are at least three reasons for this relation
ship: (1) The formation of dense networks demands more time
and energy than the formation of open networks, hence mem
bers 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.
Eelacation to Home
Once applied, the definition of deviance is partic
ularly 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


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Gordon F. Streib, Chairman
Graduate Research Professor
of Sociology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Leonard Beeghl
Associate Prof
Sociology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Lee Crandall
Associate Professor of Sociology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Michael L. Radelet
Associate Professor of Sociology


284
17h. In the past six months, has ( ) given you any gifts?
(0) No
(1) Yes
17i. In the past six months, have you provided ( ) with
any financial assistance?
17j. In the past six months, have you provided ( ) with
any personal assistance?
(0) No
(1) Yes
17k. In the past six months, have you given ( ) any gifts?
(0) No
(1) Yes


342
Markus, Elliot, Margaret Blenkner, Martin Bloom, and
Thomas Downs
1971 "The impact of relocation upon mortality rates of
institutionalized patients." Journal of
Gerontology 26:537-541.
Marsden, Peter, and Karen Campbell
1984 "Measuring tie strenth." Social Forces 63:
482-501.
McKinlay, J. B.
1973 "Social networks, lay consultation, and help
seeking behavior." Social Forces 51:275-292.
Mead, George Herbert
1977 On Social Psychology. Chicago: The University
of Chicago Press.
Mechanic, David
1978 Medical Sociology (2nd, ed.). New York: The Free
Press.
Miller, Dulcy B. and Susan Beer
1977 "Patterns of friendship among patients in a nursing
home setting." The Gerontologist 3:269-275.
Mitchell, J. Clyde
1969 "The concept and use of social networks."
Pp. 1-50 in J. Clyde Mitchell (ed.), Social
networks in Urban Situations. Manchester:
Manchester University.
1979 "Networks, algorithms, and analysis." Pp. 425-451
in Paul W. Holland and Samuel Leinhardt (eds.),
£ejspectives on Social Network Research. New
York: Academic Press.
Mueller, Daniel P.
1980 "Social networks: A promising direction for
research on the relationship of the social
environment to psychiatric disorder." Social
£iep££...and Medicine 14a:147-161.
Mutran, Elizabeth
1985 "Intergenerational family support among blacks and
whites: Response to culture or socioeconomic
differences." The Journal of Gerontology
40:382-389.


231
demonstrated for total primary and relative visiting and
speaking, closest other visiting and speaking, and total
primary and relative material linkage duration. Third,
neither closest other intensity nor ego's network emotional
bondedness levels had any effect on tie duration, further
emphasizing the importance of density on these variables.
Fourth, degree did not explain either tie duration or re
turning home, reinforcing the difference between these two
connectivity indicators that was demonstrated earlier in the
analysis of ACLF entry. Fifth, while both the inclusive
subjective measure of reciprocity and the material link
focused objective reciprocity measure were shown to affect
tie duration (in terms of contact frequency only), with the
exception of writing contact the effect of a balance of
material links was generally greater. Sixth, the influence
of network variables was shown to be the greatest on the
paths of least resistance for the focal network, i.e.,
visiting for relatives, and writing for nonrelatives.
Seventh, while visiting and speaking contact was difficult
for nonrelative members, they played a significant role in
supporting continued visiting and speaking contact by ego's
closest other. And finally, moving into an ACLF seems to
present greater contact barriers for the networks of non
whites, males, and those mentally incompetent. These re
lationships are illustrated in Figures 11-1 and 11-2.


194
latter restriction varied according to the focal network
being analyzed, with 4 omitted from the total network analy
sis, 7 from the relative network analysis, and 43 from the
nonrelative network analysis. Further restrictions in
sample size occurred in the analysis when alter was the
primary data source and lacked knowledge of time two contact
patterns with ego (n = 3). This resulted in a possible 67
observations for the total network analysis and the analysis
of closest other tie duration, 64 observations for the
relative network analysis, and only 32 observations for the
nonrelative network analysis. Additionally, when mental
health was the controlling health variable the sample size
became smaller as the mental health measurement instrument
requires direct interviewer contact with ego, and ego was
not always available for interviewing (n = 5). Unfortu
nately, the resultant small number of observations of non-
relative network variables prohibited a meaningful analysis
of their effects on returning home. However, the sample
size was adequate to analyze the effects of ego's nonrela
tive network on tie duration.
Returning Home
As was discussed in Chapter Eleven, the "problem of
return" was not inherent in ACLF entry. Sixteen percent of
those who had entered the ACLF during the summer of 1985 had
returned either to their home (n = 4) or to the home of a


54
of interpersonal commitment desired in a relationship by the
respective parties. While an "immediate" exchange strategy
(usually instrumental, strictly balanced, and with an imper
sonal 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 willing
ness to trust and to assume greater obligation" (Wentowski,
1981:604).
Wentowski's analysis emphasized the importance of bal
anced reciprocity in the maintenance of interpersonal rela
tionships. Additionally, balance was recognized as an es
sential 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 otherseither in
terms of material or psychological resources. In this man
ner 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 institutional
ization, her analysis lends support to propositions con
tending that the existence of reciprocal relationships fa
cilitates delayed institutionalization (and hence when in
stitutionalization occurs the presenting illness will be


98
under 60) was state-financed. Thus this select, new group
of ACLF residents in central Florida contains slightly more
males, nonwhites, nonmarrieds, and state-financed residents
than the statewide resident population.
As was hypothesized, the residents' presenting health
status as measured by Katz's functional, self-care index and
as charted by Pfeiffer's Short Portable Mental Status Ques
tionnaire was highly variable. There was no typical pre
senting physical or mental level of health in the new resi
dents. While 37% of the sample needed no assistance with any
of the six activities of daily living assessed in the scale,
34.6% needed assistance in two or more functions. In fact
3.7% of the sample were dependent in all six assessed areas.
A more complete picture of their presenting self-care abili
ties is illustrated in Table 6-1.
The resident's initial level of mental functioning was
also highly variable. While approximately two-thirds
(67.9%) of the sample were determined to be mentally com
petent, i.e., they demonstrated either intact functioning or
only mild impairment, the other one-third were either moder
ately or severely impaired, and hence deemed mentally incom
petent.
To check the validity of these measures, self
perceptions of ego's health were regressed on each of the
objective measures with controls added for sex and age. Ego


96
The "nonconventional" indicator of socioeconomic status
was used as it was determined from past participant observa
tion at ACLFs by the researcher to be the most meaningful
way that the residents discriminate between those "who have"
and those "who have not." Additionally, this approach pro
vides potentially useful information to the state agencies
responsible for assuming the financial burden of caring for
those "who have not." As the data indicated that alter was
the one primarily responsible for orchestrating ego's move
into the ACLF, alter was considered the primary information
source on ego's method of financing ACLF care with ego
substitutes used as necessary.
Ego's health at Time 2 and place of residence on
follow-up were also important controls when tie duration was
being analyzed. Variable measurement was identical to the
strategy used when health and location are of interest as
independent variables.


162
This weak support for the relationship between recipro
city and ego's health may be explained by the effect of
ego's declining health on his/her ability to continue to
reciprocate network members' services. If indeed, ego's
network acts to maintain ego at home for a longer period
when there are more reciprocal ties between them, as ego's
condition worsens, it is to be expected that ego's ability
to reciprocate for network services will decrease. Thus,
while there may at one time have been a difference in the
proportion of reciprocated ties between those who stayed at
home longer versus those who did not, these differences
should not be significant at the time of the move.
As was predicted, the intensity of ego's relationship
with his/her closest other tended to be directly related to
the severity of ego's presenting physical and mental health
status. However, a significant relationship was only demon
strated when analyzing the effect of nonrelative network
variables on ego's presenting mental health status
(p < .05).
This means that when ego had a nonrelative network of
greater than two members (including ego), the intensity of
ego's relationship with his/her closest other had the
greatest effect on delaying ego's ACLF entry until ego's
mental health status was quite poor. Thus, it seems that
the additional factor of the existence of two or more non-
relative close others in one's primary network increases the


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335


238
members have with one another decreases, the probability of
professional labeling and referral increases.
This is directly contrary to the demonstrated rela
tionship between density and the source of labeling and
referral. Increased density is hypothesized to limit ego's
external network contact, thus restricting his/her informal
sources of information. Alternatively, decreased degree is
hypothesized to limit ego's available internal network con
tacts, thus limiting his/her sources of information. This
later condition would then account for the negative rela
tionship between degree and informal sources of labeling and
referral. As exploration of this theoretical relationship
is limited to this study, a need remains for both more
extensive theoretical and research-oriented study of this
hypothesis.
While only the structure of the elderly's primary net
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reciprocity and intensity were also theorized to affect the
source of the elderly's "out of place" label and the sever
ity of their presenting health status. Lending support to
both network and labeling theory (Horwitz, 1977; Horowitz
and Shindelman, 1983; Lowenthal-Fiske, 1964; McKinlay, 1973,
Scheff, 1966) as well as providing new information on the
applicability of these theories in the process of institu
tionalizing the elderly, the intensity of ego's network ties


106
size drops. In ego's total network, on average, 5.6 ties
had at least one material link with ego. In the relative
subsector, a mean of 3.9 ties had at least one material
link, and in the nonrelative subsector there was a mean of
1.8 ties with at least one material link with ego. Thus,
of those people ego felt close to and was in fairly regular
contact with, an average of 20% were not materially linked
to him/her. Of those with nonrelative subnetworks (N = 63)
nearly 40% of this sector were not tied to ego by at least
one material link. And, of those with relative subnetworks
(N = 78), an average of 13% of this sector were not tied to
ego by at least one material link.
Three different types of links can connect ego and any
given network member: reciprocated, instrumental, and de
pendent. Data were collected on each of these links for
both ego's total primary network and relative and nonrela
tive subsectors. In all three networks the greatest mean
number of links was reciprocated: 5.2 (total), 4.1 (rela
tive), and 1.3 (nonrelative). Dependent links were next
most frequent in all networks with mean numbers of 3.4
(total), 2.4 (relative), and 1.0 (nonrelative). And while
instrumental ties were rare, they were not nonexistent: .8
(total), .8 (relative), and .2 (nonrelative). The high
number of reciprocated links is due, at least in part, to
the inclusion of the "carry over dimension" of reciprocity


340
Gutman, Gloria, and Carol Herbert
1976 "Mortality rates among relocated extended-care
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Habenstein, R., C. Kiefer, and Y. Wang
1976 Boarding Homes for the Elderly: Overview and
Outlook. Columbia: Center for Aging Studies,
University of Missouri.
Hammer, Muriel
1963 "Influence of small social networks as factors on
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Hammer, Muriel, and A. Schaffer
1975 "Interconnectedness and the duration of connections
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Hammer, Muriel S., Makiesky-Barrow, and L. Gutwirth
1978 "Social networks and schizophrenia." Schizophrenia
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Hawkins, Richard, and Gary Tiedeman
1975 The Creation of Deviance. Columbus:
E. Merrill Publishing Co.
Charles
Hilker, Mary Anne
1983 Shared Living in Florida; Alternative Living
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Horwitz, Allan
1977 "Social networks and pathways to primary
treatment." Social Forces 56:86-105.
Horowitz, Amy, and Lois Shindelman
1983 "Reciprocity and affection: Past influences on
current caregiving." Journal of Gerontological
Social Work 5:5-19.


Table 1-3:
Network Characteristics Sum of Squares
Bondedness to significant
other .17
Proportion of reciprocated
links
Total .92
Relative .75
Nonrelative .37
Proportion of dependent
links
Total .89
Relative .62
Nonrelative .27
Proportion of instrumental
links
Total .00
Relative .01
Nonrelative .02
Proportion of ties
perceived as balanced
Total 1.62
Relative .27
Nonrelative .00
Mean Squares
a
F
N
35.33
.00
74
.07 13.02**** 80
.08 10.00*** 78
.20 .49 51
.09 9.86*** 80
.09 6.64* 78
.21 1.26 51
.03 .14 80
.03 .19 78
.62 .04 51
.32 5.08* 79
.16 1.74 77
.19 .02 62
307


2
population 75 and over has experienced an elevenfold in
crease and the 85 and older age group has multiplied approx
imately 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 (Fowles, 1983).
Significantly, these "old-old" are the elderly who are
most likely to be limited in their activities and/or con
fined to bed due to chronic physical and/or mental condi
tions. 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 percen
tage rose from 5% for persons 65-74 to 12% for persons 75-
84, 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


203
It was hypothesized that tie duration would be directly
related to the density, degree, reciprocity, and intensity
of ego's network ties net of the pattern of contact
(visiting, speaking, and writing) and material linkages
between ego and his/her network during the year prior to the
move into the ACLF. Thus, Time 1 measures of tie duration
were controlled for by utilizing a multiple regression anal
ysis and entering them in the equation as the first indepen
dent variable. However, it was recognized that due to the
problem of autocorrelation between the error term and Time 1
contact, the influence of Time 1 contact on tie duration
would probably be biased upward (Ostrom, 1978). Controls
were also added for ego's sex, race, socioeconomic status
(females, nonwhites, and state payers were coded 1, and
males, whites, and private payers were coded 0) and ego's
level of physical and mental health at Time 2 due to the be-
tween-group differences on these variables outlined in
Chapter Seven. As with the reciprocity and connectivity
measures, physical and mental health effects were analyzed
separately to minimize any multicollinearity effects.
Additionally, ego's location at Time 2 was taken into ac
count by controlling for whether ego had returned home
(coded 0) or remained in an ACLF or nursing home (coded 1).


66
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.


13
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 analysisthe pat
tern 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, acquain
tanceship, superordination and its companion, subordination.
Just as Simmel's work directed him toward analysis of
the "countless minor syntheses" (in Wolff, 1950:9) of indi
viduals 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


CHAPTER FIVE
DATA AND METHODS
Sampling and Data Collection
The study's sample consisted of those residents aged 60
and older who were new to ACLFs (less than two months resi
dency) 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 impor
tant 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, 90, 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.
68


43
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, pos
sibly 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 physi
cians 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 in
formal network members being responsible only 50% of the
time. Correlates of this variable were only roughly identi
fied. 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 dis
charge was unlikely, with only 15% returning home. Of
significance here were the complexity of predisposing fac
tors, the duration of the condition, and the number of
prealternatives tried.


129
In terms of the interactional variable, contact fre
quency, network differences were found only in relationship
to ego's level of mental competence. There was no differ
ence in the frequency or method of network contact with ego
on the basis of ego's self-care ability. Those who were
incompetent were in less frequent written contact with both
their total personal network and relative network (p < .05)
and tended to have a greater number of visits (p < .10) with
their relative network members than did those with a compe
tent mental health status.
The difference in ego's contact by writing with network
members by mental impairment is not surprising. It is to be
expected that while one's physical health would not neces
sarily influence one's ability to communicate effectively by
mail, being mentally impaired would negatively affect this
mode of communication. However, the explanation for the
increased visiting pattern of the relative network members
of those more mentally impaired is not as obvious. The most
likely explanation is that when ego is mentally impaired,
face-to-face contact is probably the only way his/her net
work can meaningfully communicate with ego. Hence, this
mode of contact comes to be preferred by the network, and is
chosen more frequently. Conversely, one's degree of physi
cal impairment would not necessarily limit other modes of
meaningful communication, thus dispersing ego's contact
among visiting, the telephone, and writing.


283
17. Now I want to move on to some questions about your
family and friends. The last time we visited, you
identified two groups of adults with whom you had been
in contact with on a fairly regular basis the year
before you moved into the ACLF. The first group
consisted of relatives, and second was all the adults
you felt close to (excluding relatives and other
residents at this ACLF).
I have those names with me. Now for each person you
identified, I am going to ask you a series of
general questions about your relationship with them
over the past six months. [List network in charts
in back of questionnaire. Record answers to (17)
in the same chart.]
17a. Name to be inserted by interviewer.
17b. Relationship to be inserted by interviewer.
17c. In the past six months, how often have you seen ( )?
(1) Not at all
(2) Once
(3) Every other month
(4) Every month
(5) Every other week
(6) Once a week
(7) Several times a week
(8) Daily
17d. On average, in the past six months, about how often
have you talked with ( )? (Code as above.)
17e. On average, in the past six months, about how often
have you exchanged letters with ( )? (Code as
above.)
17f. On average, in the past six months, has ( ) give you
any financial assistance?
(0) No
(1) Yes
17g. In the past six months, has ( ) given you any personal
assistance?
(0) No
(1) Yes


INDEX OF INDEPENDENCE
IN ACTIVITIES OF DAILY LIVING
The index of independence in Activities of Daily Living
is based on an evaluation of the functional independence or
dependence of patients in bathing, dressing, going to
toilet, transferring, continence, and feeding. Specific
definitions of functional independence and dependence appear
below the index.
A. Independent in feeding, continence, transferring,
going to toilet, dressing, and bathing
B. Independent in all but one of these functions
C. Independent in all but bathing and one additional
function
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 additional function
G. Dependent in all six functions
Other. Dependent in at least two functions, but not
classifiable as C, D, E, or F
Independence means without supervision, direction or active
personal assistance, except as specifically stated below.
This is based on actual status and not on ability. A
patient who refuses to perform a function is considered as
not performing the function, even though he/she is deemed
able.
For each of following functions, circle that which applies
to ego. Questions are to be addressed to ego's current
primary caretaker.
259


139
Table 8-2. Frequency and percentage distribution of the
new residents' living conditions prior to ACLF
entry
Living Conditions Prior to
ACLF Entry
Frequency
Percentage
Living in own home:
Without any help
4
4.9
With help of informal network
only
18
22.2
With help of official agencies
only
1
1.2
With help of informal network
and official agencies
7
8.6
Living with family:
With help of informal network
only
34
42.0
With additional help of
official agencies
3
3.7
Living in another ACLF
9
11.1
Living in a nursing home
5
6.2
a
TOTAL
81
99.9
a
Total percentage does not equal 100.0 due to rounding.


55
more severe) and makes the possibility of deinstitutional
ization 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 care
givers 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 struc
tural characteristics of the focal population.
Vaghn and Leff (1976) and Brown et al. (1972) also
examined the influence of social variables on the probabil
ity of mental hospital readmission. However, as they looked
at the quality of expatients1 family relationships rather
than the structure of their networks, their focus was dif
ferent 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


339
Frey, James
1983 Survey Research by Telephone. Beverly Hills,
California: Sage Publications Inc.
Gluckman, M.
1955 The Judicial Process Among the Bartose of
Northern Rhodesia. Manchester: Manchester
University Press.
Goffman, Erving
1961 Asylums. New York: Anchor Books.
Gouldner, Alvin
1960 "The norm of reciprocity: A preliminary
statement." American Sociological Review
25:161-178.
Gove, Walter
1976 "Deviant behavior, social intervention, and
labeling theory." Pp.219-227 in L. Coser and
0. Larson (eds.), The Uses of Controversy in
Sociology. New York: Free Press.
Gove, Walter, and Terry Fain
1973 "The stigma of mental hospitalization: An
attempt to evaluate its consequences." Archives
of General Psychiatry 28:494-500.
Gove, Walter, and P. Howell
1974 "Individual resources and mental hospitalization:
A comparison and evaluation of the societal
reaction and psychiatric perspectives." American
Sociological Review 39:86-100.
Granovetter, Mark S.
1973 "The strength of weak ties." American Journal of
Sociology 78:1361-1380.
1981 "The strength of weak ties: A network theory
revisited." Pp. 105-131 in Peter Marsden and
Nan Lin (eds.), Social Structure and Network
Analysis. Beverly Hills, California: Sage
Publications Inc.
Greenley, James R.
1972 "The psychiatric patient's family and length of
hospitalization." Journal of Health and Social
Behavior 13:25-37.


128
degree of network openness, the greater degree of impairment
in ego's health status at the time of his/her move into the
ACLF may be explained by the decreased number of information
channels to assist with the labeling and referral of ego's
problem. This then, may result in the overlooking of ego's
problem until it becomes relatively severe.
As is discussed in Chapter Nine, another, possibly more
important set of explanations, may be contained in the
"supportive" character of dense networks. The greater per
centage of internetwork linkages may allow for more dis
persion of the burdens of caring for ego in his/her home or
the home of a network member, as well as increase the pres
sure on network members to continue to assume those respon
sibilities. This would contribute to the postponement of
ego's relocation until his/her condition became more severe.
Yet, while those who were able to delay their relo
cation into an ACLF until they were more impaired belonged
to more dense total personal networks, those networks were
not more emotionally bonded to ego. The association between
mean network emotional bondedness and ego's health was only
present in ego's nonrelative sector, and this was only true
when ego's physical health was analyzed. Those who were
more limited in their self-care abilities when they came to
the ACLF were more emotionally bonded to their nonrelative
network (p < .05).


195
relative (n = 8). In an attempt to explain this phenomenon,
logistic regression was used to regress returning home on
the network variables reciprocity, intensity, density, and
degree at the time of ACLF entry, with the probability of
remaining in an institution indicated by Y = 1. As these
exogenous variables are not serial, the problems related to
multicollinearity, autocorrelation, and degrees of freedom
in time-lagged variables discussed in Ostrum (1978) did not
need to be addressed. Controls were added for ego's physi
cal and mental health at Time 2, as well as ego's race
(whites coded 0, nonwhites coded 1), sex (males coded 0,
females coded 1), and socioeconomic status (private payer
coded 0, state payer coded 1). Ego's physical and mental
health at Time 2 were analyzed separately, minimizing the
effects of multicollinearity. However, due to the nonvari
able effects of mental health on going home (i.e., all of
those who went home were assessed as mentally competent with
Pfeiffer's Short Portable Mental Status Questionnaire), only
the control of physical health remained in the analysis.
The resultant sets of equations are presented in
Appendix K, Table K-l. In terms of the hypothesized rela
tionships, the intensity of ego's ties with his/her personal
network at the time of the move into the ACLF was the only
network variable that was significantly related to reloca
tion home at Time 2. There was no relationship with the


91
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),
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;


109
reciprocity. Thus, it is not surprising that the percentage
of symmetric links between ego and alter is considerably
less than the percentage of reciprocated links reported in
this study. For Wellman, symmetry was the exception rather
than the norm, especially in the case of major resources.
Sokolovsky et al. (1978) also reported data on tie
directionality in their study on residents of single room
occupancy hotels. As in this study, they too, looked at
directionality from a reciprocity perspective. While reci
procity predominated in those without any psychosis both in
relationships within and outside of the hotel, for those
with either active schizophrenia, or a history of psychosis,
reciprocity was rare within the hotel, and only slightly
more prevalent than dependency with those outside hotel
relationships. Thus, dependency was much more common in
this group than those without psychotic symptoms.
Finally, Cantor (1979) focused on understanding the
nature of dependency among low-income New York elderly. She
reported (as does this study) that in terms of material
tasks, kin formed the predominant links to ego. However, in
terms of affective assistance (nonmaterial links), the pro
portion of links between relatives and friends was fairly
evenly split. This may be explained by the norm of reci
procity. Material links are more likely to be reciprocated
with relatives than with nonrelatives (note the higher


102
mean numbers of functional friends (seen at least monthly or
in phone contact at least weekly) and functional neighbors
(known well and interacting with in one or more instrumental
ways) were reported. As most functional friends were found
to be neighbors, this latter category can be roughly under
stood to subsume that of friends and may be similar in
meaning to this study's category of nonrelative primary
group members.
Cantor found these low-income, noninstitutionalized New
Yorkers to have a mean of .66 functional friends and 2.1
functional neighbors. While this latter number is slightly
less than this researcher's finding of a mean of 2.8 non-
relative primary group members, as Cantor's sector includes
most, but not all of the respondents' friends, our findings
are interestingly close.
Wellman's 1981 study (coincidently also of New Yorkers)
reports some comparable network data on a younger adult
population. Although, as with Cantor's work, no attempt was
made to quantify such definitions as "close" or friendship,
Wellman delineated active network sectors of intimates (all
ties defined as close), sociables (all ties whose company is
enjoyed and whose absence would be missed), and supportives
(ties who give at least one type of supportive aid). The
latter category seems to most closely reflect the total
personal network as defined in this study. The reported


Table J-3
Variable effects on ego's presenting mental health status, by connectivity
measure and focal network, unstandardized regression coefficients
Focal Network
Connectivity Measurea
Total
(N =
Primary
77)
Relative
(N = 74)
Nonrelative
(N = 38)
b
SD
b
SD
b
SD
Density
.02***
.01
.01
.01
.01
.01
SES
-.21
.37
-.29
.41
-.21
.42
Sex
.08
.26
-.18
.27
-.29
.36
Race
-.36
.38
-.25
.44
-.17
.47
Network bondedness
-.02
.04
.03
.04
-.07
.07
Significant other bondedness
.07*
.05
.04
.06
.15**
.07
Reciprocity"obj ective"
.60*
.45
.31
.49
-.36
.37
Reciprocity"subjective"
2
-.30
.33
-.30
.37
-.47
.35
R
.21
.11
.26
Degree
-.07
.05
-.09*
.05
.03
.08
SES
-.38
.39
-.42
.41
-.29
.44
Sex
-.22
.27
-.22
.26
.41
.34
Race
.03
.40
.06
.43
.12
.48
Network bondedness
-.02
.05
.03
.04
-.05
.07
Significant other bondedness
.07
.05
.05
.05
.15**
.07
317


140
length about the general unmanagability of keeping ego at
home. For example,
[Ego] did crazy things. ... He needed constant
care. Once he stuck a screw driver in a socket
thinking he was putting a key in a lock.
(a daughter)
When she urinated all over the $6,000 new carpet;
that really made me angry. (a daughter)
I was afraid for Grandma's life if I kept her
home any longer. ... It got to the point
where I had to put bars on the windows to keep
her in the house. . And then she tried to
squeeze through the bars. (a granddaughter)
The hospitalization of ego was another type of critical
incident that acted to push ego into an ACLF. As approxi
mately one-fifth of the new residents had been in the hospi
tal just prior to their move into the ACLF, the occurrence
of this incident may be commonly perceived as the proverbial
straw that broke the camel's back. However, interviews also
revealed that for some hospitalization was used as an excuse
to get new residents out of their homes and involve profes
sionals in moving them into another living situation. In
this case network members had already perceived a need to
relocate ego, but had not as yet been able to communicate
that need to ego. The real purpose of hospitalization,
thus, was to dissipate the blame for moving new residents
out of their homes.
In approximately one-fifth of this sample the tolerance
of ego's network for ego's demands was limited by the recent


167
deficient in their relative networks (p < .05) were more
likely to be formally than informally labeled as "out of
place" in their current environment, and the professional
mentioned was always one other than a physician. In fact,
all of those with deficient total networks were formally
labeled.
The more prevalent role of professionals in
orchestrating the move of those with deficient total and
relative networks was also demonstrated in the differential
source of ACLF referral. Once again, the professional
mentioned was always one other than a physician. However,
in this case only the total network deficient group was more
likely to be professionally referred (p < .05).
As with the nondeficient group, once the decision was
made, delays and discouragement were unusual. In fact, none
of these people identified any discouragement from others in
regard to their move, and only one of them experienced any
delay after their decision was made.
Deficient Nonrelative Network
The demographic profile of those with a nonrelative
deficient subgroup was not significantly different than that
of those with two or more nonrelatives to whom they felt
close to and with whom they were in fairly regular contact.
A chi-square analysis revealed no difference in the sex,
socioeconomic status, race, or marital status between them.


Table J-lContinued
Focal Network
Total Primary
(N = 77)
Relative
(N = 74)
Nonrelative
(N = 38)
Connectivity Measure
Logit SD
Logit SD
Logit SD
Reciprocity"objective" -1.66 1.45 -1.31 1.11 -.24 .19
Reciprocity"subjective" .77 .87 .47 .84 .90 .97
*p < .10.
**p < .05.
***p < .01.
a
While this table includes both measures of reciprocity, they were regressed on labeling
seperately. The reported logit coefficients of the remaining variables are from the
regression with the "objective" measure of reciprocity. No measurable difference in
the coefficients emerged with the subjective measure of reciprocity.
315


36
rules. In their discussion of "Share-a-Homes," 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 recog
nized 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 ex
changes. In this case it is likely that the depth and
breadth of the relationships will compensate for ego's


EMOTIONAL BONDEDNESS SCALE
1. I can count on this person to stand by me.
2. Sometimes makes me angry or upset.**
3. Is sensitive to my feelings and moods.
4. Listens to my problems and worries.
5. Sometimes hurts my feelings.**
6. Thinks highly of what I know and can do.
7. Sometimes makes me discouraged.**
8. Often cheers me up.
9. We see eye to eye on most things.
10. We often have trouble getting along together.**
11. We really enjoy spending time together.
12. We get along better with each other when we keep our
feelings to ourselves.**
**Reverse coded items
To each of these items the individual responds with one
of the following: Not at all true of him/her, somewhat true
of him/her, or very true of him/her. Scores range from 1 to
3 for each item, with 3 denoting high emotional bondedness
(Snow and Crapo, 1982).
255


57
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 institu
tionalized 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 grand
children in their social support networks.
However, while the study was somewhat more sophis
ticated than those others mentioned to this point, due to
its sample size and utilization of extensive multiple re
gression equations, the validity of its social support indi
cator 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 vein, Wells and MacDonald (1981) examined
the relationship of the elderly's network to the process of
interinstitutional relocation. Longitudinal data were col
lected on 56 extended-care residents of one of Toronto's
homes for the aged prior to and 8-12 weeks following non
voluntary 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 nonresi
dent friends that were in the residents' networks both
before and after the move occurred. Not surprisingly, relo
cation had a disruptive effect on primary relationships,


38
of the ACLF resident, this implies that once the transition
from one's home has been completed, there is a low likeli
hood 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 main
tained ego's return home is still unlikely.
As previously discussed, tie duration is positively
related to tie intensity, tie reciprocity, and network den
sity. 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 con
dition 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, relo
cation is only likely if network normative pressure is great
enough to result in the further network behavioral adjust
ments 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 open, the conditions that lead to what
may be perceived as "premature" placement are not likely to


18
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 net
work 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).
Interactional Concepts
In contrast to morphology, which describes network
attributes, interactional network characteristics delineate
linkage attributes. Included in this category of analysis


76
strategy was followed in lieu of Cubbitt's (1973) obser
vation that general network characteristics may mask signi
ficant different characteristics in sections of the network.
Data were obtained via a two-phased approach. Respon
dents 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 data, 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 in
clusionary criteria were not met for any identified person,
he/she was then excluded from ego's inner circle of con
tacts. 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 respon
dent-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


227
reciprocity. These results are presented in Appendix K,
Table K-4.
Time 1 total and relative network material links are
significantly related to Time 2 levels of material linkages.
As Time 2 levels were significantly lower than Time 1 levels
(see the discussion in Chapter Ten), this indicates that the
level of decline is predictable by the networks prior level
of material links with ego. However, this did not hold for
ego's nonrelative subsector. Time 1 levels did not explain
levels of material links at Time 2, once again suggesting
that ACLF entry poses significant tie maintenance barriers
for ego's nonrelative network.
Although the effect of density on network material
linkages at Time 2 is less than its effect on network
visiting and speaking contact frequency at Time 2 (see
Appendix K, Tables K-2 and K-4), a positive tendency remains
in spite of the greater restrictiveness of the indicator
used in this portion of the analysis (p < .10) Thus,
further support is lent to the study hypothesis:
Tie duration is a positive function of network density.
The finding that density is the only network variable
that explains Time 2 material links is explained by the
influence of barriers related to ACLF entry on the positive
tie continuity effects of "strong networks." It is more
difficult for network members to continue to exchange ser
vices with ego then to remain in contact with him/her after


155
referring ego to an ACLF as a response to his/her lack of
fit. In this case, it is likely that a response for ego's
lack of fit will be sought from a health professional.
Utilization of the ACLF, then, becomes contingent upon the
transmittal of this information by the professional to ego's
closest other.
While the relationship between degree and referral is
not significant, the logit of degree is consistently nega
tive in its effect on both labeling and referral. This is
directly contrary to what was predicted and indicates that
as the average number of relationships members have with one
another decreases, the log odds of both professional
labeling and professional referral increases.
This suggests that this connectivity indicator affects
network information rendering somewhat differently than
density. An explanation may be found in the confounding
variablesize. While density is the percentage of poten
tial connections that do in fact exist, degree measures the
average number of connections that exist between network
members. Thus, while density is proposed to affect the
external availability of information to network members, it
seems that degree affects the availability of information to
network members from within the network. As the average
number of relationships members have with each other
decreases, the potential sources of information among


177
While Dad was at the ACLF, I spent time with his
affairs. I think he will be more independent of me
now that he is in the nursing home. (a daughter)
Perceived-Eit
Most of the respondents expressed a high level of
satisfaction with both the physical care and the emotional
atmosphere at the ACLF. In terms of ego's physical care,
54% of the respondents felt that the physical care ego had
received at the ACLF he/she had moved into six months
earlier was excellent, and an additional 33% felt that ego's
care had been at least adequate. Yet, nine (12%) of the
respondents felt that this care had been less than adequate.
Dissatisfaction with ego's care most frequently was attri
buted to high staff turnover, inadequate staff training, and
inadequate dietary provisions.
An even greater 78% of the respondents felt that the
caregivers at that ACLF were not only pleasant, but, addi
tionally, they felt that they really cared about them. Thus,
it seems that the "homelike" perception ego and alter held
of the ACLF at the time of ego's move was generally con
firmed. The generally high satisfaction level of the resi
dents and their network is expressed in the following com
ments :
I was scared to stay alone. I don't like to
have an apartment again. I feel better here. I
have no more pain. I can sleep better at
night, (a female resident)


219
Returning to the individual variable effects, with the
exception of the regression of Time 2 closest other contact
on the nonrelative network variables, each of the Time 1
closest other contact levels was related to Time 2 contact
levels. In fact, while the model as a unit explained most
of the variance in Time 2 visiting, Time 1 closest other
speaking accounted for almost all of the variance in Time 2
closest other speaking (see Appendix K, Table K-3). As
closest other visiting and speaking contact do decline after
ACLF entry, the level of these declines can then, at least
in part, be explained by the prior level of contact.
As before, the direct relationship between Time 2
visiting contact and network density is strong for ego's
total primary and relative networks (see Table 11-3 and
Appendix K, Table K-3). This leads to the conclusion that
network density affects both the tie duration of the network
as a group and the duration of the ties with whom ego holds
the closest bonds. Further support is thus added to the
hypothesized direct relationship of density to tie duration.
In fact, while nonrelative network density did not
explain nonrelative visiting, in this analysis the effect of
density holds for all three networks. The higher the
density of ego's nonrelative network, the more frequently
ego's closest other visited ego after ACLF entry (p < .10).
In addition to supporting the hypothesized relationship
between density and tie duration, this finding adds further


26
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 indi
vidual 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. Further
more, this minimal level of contact is likely to vary from
one situation to another depending on operating social ex
pectations.
Thus, 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
ties, 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.


50
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 inten
sity. 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


272
3. In general, how was ego feeling at that time?
Very good
Good
Fair
Poor
4. Who first suggested that moving into an ACLF might
be a good idea for ego?
A relative of ego
A personal contact of ego's
Ego's doctor or another health professional
(i.e., a nurse or a social worker)
Ego determined it him-/herself
5. Could you briefly explain how ego felt about moving
to an ACLF? (Was it a last alternative? Preferred
over going to a nursing home? Resisted at all
costs? The best available option?)
6 Did any of ego's relatives or personal contacts
discourage him/her from moving to an ACLF?
Yes
No
7. Once the decision was made to move ego to an ACLF,
was the move delayed due to
Lack of space in the ACLF of your choice
Financial problems
Difficulties in selling ego's home or other
possessions
Other
No delays were experienced
8. Which of the following best describe how ego pays for
his/her care at this ACLF?
Care is paid by ego
Family pays for care
State of Florida pays for care
Other
9 I would like you to identify two groups of people. In
the first group, will you please include all of the
relatives that ego has been in contact with on a
fairly regular basis in the past year. (By a contact,
I mean either a phone call, a letter, or a visit.)


188
a statistical increase between the mean written communica
tion from time one to Time 2, there is no meaningful
difference in written contact between ego and network mem
bers during this period. The statistical difference can be
accounted for by the difference in scales used at Time 1 and
Time 2. Actually, both before and after the move into the
ACLF, ego appears to be in written contact with network
members about once or twice a year. This was usually
identified as being in the form of a card for Christmas
and/or ego's birthday.
lie Content and Diiectedness
Mean network material links with ego were also computed
at Time 2. Not surprisingly, there was a significant
decrease in the average number of material links connecting
ego and primary network members since ego had moved into the
ACLF (see Table 10-3). The decrease in material links was
demonstrated for instrumental, dependent, and reciprocated
links in all three of ego's focal networks.
Yet, while there was a significant decrease in ego's
material links with primary network members, network members
continue to exchange services, gifts, and financial assis
tance with ego after the ACLF move. Six months after ego
had moved into the ACLF, he/she was on average connected
with 7.3 material links to primary network members. As was
the case before ego moved into the ACLF, these material


114
contact with each other, the density of these combined
sectors is, on average, quite a bit lower.
The majority of these close others are still materially
bonded to ego, with the highest percentage of these links
being reciprocated. While relatives have a higher number of
material links to ego, nonrelatives are more highly emotion
ally bonded to ego, and are in more frequent visiting and
speaking contact with him/her. Thus, the functions these
two sectors provide to ego seem to compliment each other.


230
As for location, while remaining in an ACLF does tend
to be negatively related to material linkage duration, this
effect is much weaker than was expected (see Appendix K,
Table K-4; and Table 11-4). Only when the total primary
network is taken into account does an effect emerge, and
this is at p < .10. This indicates that those that go home
do not have many more material linkages with their network
then those who remain in the ACLF. This finding is consis
tent with the previously reported negative association bet
ween going home and network emotional bondedness as well as
the finding that going home was only selectively associated
with more frequent network contacts with ego. Thus, in
tandem, these results support the theorized relationship
between negative structural and contextual network relation
ships and less restrictive institutional placement criteria.
In conclusion, network variables and the controls were
related to tie duration and returning home in eight ways.
First, in addition to being in better health, those that
went home were nonwhite, were paying for their care by them
selves or with the help of their network, and came from
networks to which they were less emotionally bonded. Addi
tionally, those that returned home were only in more fre
quent total network visiting and nonrelative speaking con
tact than those who remained in the ACLF. Second, density
emerged as the strongest and most consistent variable ex
plaining tie duration, with positive relationships


175
six months later. This means that over one-third of this
sample had either relocated (n = 22) or died (n = 6) within
six months of their move into the ACLF. Interestingly, more
residents had moved home (n = 12) during this initial six
months than had moved to another ACLF or to a nursing home
(n = 10). Of those, 16% returning home, four had returned
to their own home and eight had returned to the home of a
relative. While this pattern is consistent with that
reported in Liu and Mantn's review (1983) of nursing home
length-of-stay patterns and Hilker's share-a-home study
(1983), it is quite different from that reported in Allison-
Cooke's study (1982) of nursing home deinstitutionalization
patterns (see Chapter Four).
Thus, the "problem of return" as discussed by Hawkins
and Tiedeman (1975) was not inherent in ACLF entry. Yet, it
could be that only those whose "out of place" label was
conditionally legitimate (i.e., that their illness was
assumed to be acute) were likely to return home. In fact,
all of those who moved back to their own homes had told the
researcher at Time 1 that they were only intending to be at
the ACLF for a short time, and then were to return home.
These people were using the ACLF as a short-term caring
institution. Three were recovering from illnesses that no
longer required hospitalization, but they were still not
well enough to function independently at home. One had been


141
or ongoing illness of another network member. Either ego's
spouse, an in-law, or possibly a son or daughter, had just
died from or was currently struggling with a serious chronic
illness. Given that 54.3% of this sample were over 80 years
old, this is not too surprising. In these instances it
seems that ego was unfortunate enough to be the second one
to demand extensive care from his/her personal network, and
while that same network had often been able to provide this
support for its first failing member it was "too burned out"
to provide it for ego. Additionally, alter frequently ex
pressed a feeling of having eased any sense of obligation
"to do for" ego by already caring for another ailing network
member. As one respondent explained, "After spending all of
that time caring for his mother, I don't think people can
expect us to do it again."
Given that this move was generally undertaken when all
else failed, it is somewhat surprising that 94.7% of the
alters stated at the initial interview that they were gen
erally happy with ego's move into the ACLF. However, it
should be noted that this satisfaction was usually cushioned
with the attitude that the ACLF environment was "so much
better for ego than it would be in a nursing home." This
attitude of relative satisfaction with the move best
expressed by some of the alters themselves.
Mom doesn't need a nursing home now. She would
be insulted, (a daughter)


293
18h. In the past six months, has ( ) given ego
(0) No
(1) Yes
18i. In the past six months, has ego provided I
financial assistance?
(0) No
(1) Yes
18j. In the past six months, has ego provided
personal assistance?
(0) No
(1) Yes
18k. In the past six months, has ego given ( )
any gifts?
) with any
( ) with any
any gifts?
(0)
(1)
No
Yes


156
network members decreases. As this researcher has deter
mined that the knowledge of ego's closest other is most
critical in the labeling and referral process, it is then
hypothesized that as the degree of ego's closest other's
network increases and, hence, the potential within-network
sources of information increases, the likelihood of profes
sional labeling and referral decreases. Testing of this
hypothesis remains for future research efforts.
Returning to the control variables, as socioeconomic
status explained the source of both the "out of place" label
and ACLF referral, the analysis was taken a step farther to
determine if the source of labeling would predict the source
of referral. Controlling for ego's socioeconomic status,
sex, and race a highly significant finding emerged between
the source of ego's "out of place" label and the source of
ego's referral (p < .001). The network that initiates the
process of moving ego into an assisted living situation will
most likely decide the location of ego's move.If ego is
labeled by a professional it is very likely that he/she will
be referred to the ACLF by a professional. Similarly, if
ego is labeled "out of place" by a member of his/her primary
network, it is very likely that ego will be referred to an
ACLF by a primary network member.


200
Pfeiffer's highest level of mental competence. Thus, while
contingencies are important in explaining ego's location at
Time 2, the magnitude of the importance of ego's health in
explaining this phase of the institutionalization process is
encouraging. The "problem of return" does not seem to be
inherent in ACLF entry, suggesting either that this illness
career is measurably different than that of those institu
tionalized with mental health problems (Goffman, 1961;
Greenley, 1972; Scheff, 1966) or rendering support to the
hypotheses that while the process of institutionalization is
influenced by social and cultural variables, the "objective"
health state of an individual is of more primary importance
(Gove, 1976; Gove and Fain, 1973; Gove and Howell, 1974).
The relationship between race and returning home was
positive, with nonwhites more likely to return home than
whites. This finding may be explained both by different
cultural expectations between nonwhites and whites to care
for their elderly at home and in network theory. Assuming
normative pressures to care for the elderly members of one's
personal network are stronger for nonwhites (Wylie, 1981)
and, given that nonwhite new residents are more "tightly
glued" to their networks emotionally and structurally (see
Chapter Seven), it follows that the networks of nonwhites
would facilitate the dispersion of group pressure of the
normative value to return ego home. Thus, while network
connectivity was not related to return home, the proposed


107
in the data on personal assistance directed from ego to
alter. Past assistance from ego to alter was considered as
a material link. Thus, if ego was currently receiving
material aid from a network member in one of the three
assessed areas, and ego had rendered personal assistance to
that person in the past, this linkage would be considered
reciprocated.
These numbers can also be translated to indicate the
mean percentage of the total links in each network that are
of each pattern. Once again the majority of the links are
reciprocated: an average of 52.3% of the links in the total
network, 50.0% in the nonrelative network, and 56.5% in the
relative subsector. Yet, ego has, on average, a large
percentage of dependent links: 38.% of the total links are
dependent, 46.4% of the nonrelative links, and 33.7% of the
relative links are dependent.
Possibly the most interesting finding that becomes more
apparent when the data are viewed from this perspective is
the percentage of linkages that were instrumental. In ego's
total network an average of 8.2% of the links are instru
mental. In the subfields, 13.3% of the nonrelative and 9.8%
of the relative links are unidirectional from ego to alter.
Again, it should be noted that a good portion of these links
are probably due to past personal assistance by ego to alter
that is not currently being "repaid" in any material manner
by alter.


Table 1-2. Analysis of network characteristics by race, controlling for respondent's sex,
socioeconomic status and mental health
a
Network Characteristics Sum of Squares Mean Square F N
Size
Total
1.84
16.28
.11
81
Relative
.99
8.26
.12
81
Nonrelative
.04
8.11
.00
81
Size without material links
Total
.15
11.23
.01
81
Relative
1.95
6.18
.29
81
Nonrelative
3.31
4.90
.68
81
Density
Total
1858.06
394.48
4.71*
77
Relative
1443.29
213.63
6.76*
74
Nonrelative
2444.42
604.85
4.04
46
Degree
Total
34.66
6.45
5.37*
77
Relative
24.16
6.69
3.61
74
Nonrelative
18.61
4.47
4.16*
46
Mean bondedness
Total
125.01
8.76
14.28***
80
Relative
146.23
15.10
9.68**
78
Nonrelative
53.14
9.37
5.67*
63
303


81
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 an
swers 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 basi
cally one of increased dependence. Essentially, ego's con-


184
after the move into the ACLF. This is illustrated in Table
10-1. Similarly, while speaking contact with ego's closest
other, who was a relative for 78% of the respondents, did
decline after ACLF entry (p < .05) there was no significant
decrease in visiting frequency between ego and ego's closest
other.
The demonstrated continuity in visiting patterns with
ego's relatives may be partially explained by the proximity
of the ACLF to the home or office of the relatives who had
been in most frequent contact with ego prior to the move.
As discussed earlier, alter frequently reported that when
the decision was being made for ego to enter into an ACLF
the proximity of the ACLF to the home or work place of ego's
relatives was an important discriminating variable.
While this strategy was successful in facilitating
visiting continuity between ego and his/her relatives, it
did not facilitate continuity in visiting between ego and
those nonrelatives whom he/she had been close to. ACLFs
were frequently distant from the homes of these network
members. As most of these nonrelative others were also
older, it is likely that transportation barriers might have
limited nonrelative tie continuity. It was unusual for an
ACLF to be on a bus line, and driving for many of these
older network members may have been problematic. Many of
these nonrelative primary group members directed their


78
needed to be identified. Material links were defined in
terms of the existence of any one of three types of assis
tance: personal assistance, money or loans, or other gifts.
As links can flow both to and from ego, data on both instru
mental and dependent links were obtained, yielding a poten
tial range of 0-3 material links between ego and a network
member.
Measurement of Dependent Variables
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 six-
month 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-


314
Table J-l
Variable effects on the log odds of formal vs. informal sources of out of
place labeling, by connectivity measure and focal network
Focal Network
Total Primary
(N = 77)
Relative
(N = 74)
Nonrelative
(N = 38)
a
Connectivity Measure
Logit
SD
Logit
SD
Logit
SD
Density
-.02
.01
-.01
.02
-.01
.02
SES
1.71*
.99
1.36
.92
1.17
1.00
Sex
-1.10
.69
-.47
.62
-1.25
.96
Race
.78
1.06
-.33
1.03
1.27
1.16
Network bondedness
.34**
.15
.14*
.09
.11
.19
Significant other bondedness
.22
.15
-.13
.13
-.28
.92
Reciprocity"obj ective"
-1.86
1.18
-1.41
1.41
.10
.18
Reciprocity"subj ective"
.82
.89
.39
.84
.83
.99
Degree
-.10
.13
-.10
.13
-.19
.21
SES
1.94**
.96
1.29
.93
1.52
1.07
Sex
-.87
.65
-.38
.62
-.97
.89
Race
-.95
1.05
-.30
1.02
1.33
1.18
Network bondedness
.34***
.15
.14*
.09
.10
.18
Significant other bondedness
-.20
.15
-.12
.13
-.24
.19


61
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 cur
rently 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 under
stood 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 insti
tutionalization, his research did test the related hypo
thesis 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.


Table i-lContinued
Network Characteristics Sum of Squares
Bondedness to significant
other .00
Proportion of reciprocated
links
Total .07
Relative .02
Nonrelative .24
Proportion of dependent
links
Total .00
Relative .15
Nonrelative .13
Proportion of instrumental
links
Total .03
Relative .00
Nonrelative .34
Proportion of ties
perceived as balanced
Total .26
Relative .00
Nonrelative .12
Mean Square
a
F N
35.33
.00
74
.07 1.07 80
.08 .26 78
.20 1.20 51
.09 .04 80
.09 .44 78
.21 .61 51
.03 .98 80
.03 .13 78
.62 .55 51
.32 .80 79
.16 .03 77
.19 .65 62
301


159
Table 9-1. Variable effects on ego's presenting health
severity, standardized regression coefficients
(N = 77)
Effect
on Ego's
Effect on
Ego' s
Mental
Health
Physical
Health
Variable Name
B
SD
B
SD
Total density
.38***
.01
.29**
.01
Total network
bondedness
-.07
.04
.13
.08
Closest other
bondedness
.19*
.05
.07
.09
Total network
reciprocity
"objective"
.17*
.48
-.05
.79
SES
-.08
.37
-.04
.66
Sex
.04
.26
.11
.47
Race
-.13
.38
-.09
.68
2
R
.21
.09
*p < .10.
**p < .05.
***p < .001.


344
Ryden, Muriel
1984 "Morale and perceived control in institutionalized
elderly." Nursing Research 33:130-136.
Ryden, Muriel
1985 "Environmental support for autonomy in the
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1979 "Social myth as hypothesis: The case of the family
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"Toward a resolution of methodological dilemmas in
7:109-116.PP 9* Schizophrenia


APPENDIX I
BETWEEN-GROUP NETWORK DIFFERENCES


TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS
ABSTRACT V
CHAPTER
ONE INTRODUCTION 1
Caring for the Elderly 1
The Adult Congregate Living
Facility 5
Theoretical Gaps 7
The Focal Problem 9
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 35
Relocation to Home 37
FOUR LITERATURE REVIEW:
NETWORK VARIABLES AND
INSTITUTIONALIZATION 40
FIVE DATA AND METHODS 68
Sampling and Data Collection 68
Network Delimitation 75
Measurement of Dependent Variables ... 78
Measurement of Independent
Variables 87
iv


Table J-3Continued
Connectivity Measure
Focal Network
Total
(N =
Primary
= 77)
Relative
(N = 74)
Nonrelative
(N = 38)
b
SD
O'
CD
D
b
SD
Reciprocity"obj ective"
.51
.48
.23 .48
-.42
.38
Reciprocity"subjective"
-.31
.34
-.14 .36
-.47
.34
2
R
.11
.13
.24
*p < .10.
**p < .05.
***p < .001.
a
While this table includes both measures of reciprocity, they were regressed on ego's
health separately. The reported coefficients of the remaining variables are from the
regression with the objective measure of reciprocity.
318


Table 1-4. Analysis of variance of network characteristics by respondent's physical and
mental health, controlling for race, sex, and socioeconomic status
Sum of
Squares
Mean Squares
Fa
Network Characteristics
Physical
Health
Mental
Health
Physical
Health
Mental
Health
Physical
Health
Mental
Health
N
Size
Total
27.11
58.21
16.69
16.28
1.62
3.58
81
Relative
.18
15.10
8.46
8.26
.02
1.83
81
Nonrelative
25.96
17.70
8.00
8.11
3.25
2.18
81
Size with material links
Total
5.69
20.79
11.43
11.23
.50
1.85
81 o
Relative
.11
9.24
6.94
6.81
.02
1.36
81 ^
Nonrelative
3.98
4.90
4.88
4.90
.82
2.55
81
Density
Total
2143.70
4972.28
433.77
394.48
4.94*
12.60**
77
Relative
164.78
475.04
218.13
213.63
.76
2.22
74
Nonrelative
25.10
115.78
607.07
604.85
.04
.19
46
Degree
Total
.01
6.76
6.54
6.45
.00
1.05
77
Relative
2.06
20.82
6.97
6.69
.30
3.11
74
Nonrelative
2.01
6.41
4.58
4.47
.44
1.43
46
309


266
lia. I can count on this person to stand by me.
lib. Sometimes makes me angry or upset.
11c. Is sensitive to my feelings and moods.
lid. Listens to my problems and worries.
lie. Sometimes hurts my feelings.
llf. Thinks highly of what I know and can do.
llg. Sometimes makes me discouraged.
llh. Often cheers me up.
Hi. We see eye to eye on most things.
llj. We often have trouble getting along together.
llk. We really enjoy spending time together.
lll. We get along better with each other when we keep our
feelings to ourselves.
12. When you consider everything that you share with ( ),
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 ( )?
13. Who would you consider to be the person closest to you
who lives in the Orlando area?
14. Would you mind if I contacted your closest contact and
asked him/her some similar questions?
Yes
No
15. What is his/her address and phone number?
16. How old are you?
60-64
65-69
70-74
75-79
80 +


191
The focus at Time 2 was only on exchanges that had
occurred between ego and network members since the ACLF
move. If ego was only linked to alter on the basis of
services rendered to alter in the past, this link would no
longer be counted. Thus, a reciprocal link would be
redefined as a dependent link and an instrumental link would
then be broken.
Changes in the nature of network linkages with ego
after ACLF entry may also be due to ego's role redefinition
by network members. Qualitatively derived data indicate
that with the move network members commonly redefine their
expectations of ego, excusing him/her from behaviors that
had been expected in the past. A primary past obligation
that is "let go" is that of gift giving. Yet, although ego
is no longer expected to give network members gifts, gifts
are frequently still given to ego. Thus, what had been a
reciprocated link becomes a dependent one. This is well
illustrated in the following comments by alter:
She doesn't buy gifts anymore. Before she moved
in, I used to do that. ... It didn't mean much
anyway, because it was from me. (a daughter)
This was a good time to quit that. . Her
son talked her out of buying gifts anymore since
she moved into the ACLF. (a stepdaughter)
In conclusion, while both the new residents and their
significant others are generally quite satisfied with the
physical and emotional care ego is receiving at the ACLF,
directions for improvement did emerge. In the area of



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165
reason for this definition is primarily due to the fact that
density and degree figures are meaningless for networks of
this size, and hence the data on these individuals is lost
from all analyses that examine or control for density and
degree. It is also recognized that frail elderly people
with very small or nonexistent personal networks are more at
risk of institutionalization. Thus, it is important that
data on this subgroup be examined.
It was unusual for the new residents to have no more
than one person that they felt close to and had been in
regular contact with prior to entering the ACLF. Only 4.9%
(n = 4) of the sample had this sparse a total primary
network. Similarly, all but seven (8.6%) of the respondents
were in regular contact with at least two relatives whom
they felt close to. However, 45.7% of the sample had a
deficient nonrelative network. Thus, it was not unusual for
these people to come to the ACLF with only one or no
nonrelatives whom they felt close to.
iQient Total nd Rlat.iye N£..t.wQik5
Due to the small number of respondents with a deficient
total primary network and/or a deficient relative sector,
Fisher's exact test was used to determine if significant
differences existed between these groups and those who had
at least two members in each of these networks. As the size


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Pamela Richards
Associate Professor of Sociology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Otto Von Mering
Professor of Anthropology
This dissertation was submitted to the Graduate Faculty of
the Department of Sociology in the College of Liberal Arts
and Sciences and to the Graduate School and was accepted as
partial fulfillment of the requirements for the degree of
Doctor of Philosophy.
December 1986
Dean, Graduate School


6
common. Additionally, standardized national licensing cri
teria 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 disser
tation was done.
Statistics indicate that the ACLF is far from an insig
nificant phenomenon in Florida. As of December 1984, there
were 1,180 licensed ACLFs in Florida, housing 39,500 resi
dent 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.


77
during the past year to be considered a member of ego's
inner circle. "Several times" was defined as existing be
tween 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 neighbor
hood boundedness of many of the resident's peer friends and
family (Cantor, 1979), a contact was not restricted to vis
iting. 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 sup
port 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 operation
alizing the degree of friendship in a relationship and the
degree of closeness in relative links. The scale is a 12-
item 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 "some
what" bonded) was necessary or at least one material link


73
intellectual functioning (0), mild (or borderline) intel
lectual 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 abili
ty was measured to be intact or only mildly impaired, ego
was considered the primary survey informant and the inter
view 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 ego, 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."


202
entry. Thus, in addition to ego's health status, ego's
network bondedness, ability to pay for care, and race also
play a significant role in orchestrating his/her illness
career. These relationships are illustrated in Figure 11-1.
Figure 11-1. Variable effects on returning home
Note: Reciprocity, density, degree, closest other
intensity, and sex are omitted as they were not
significant at p < .05.
lie Duration
As discussed in Chapter Ten, moving into the ACLF
resulted in highly significant decreases in ego's primary
network tie duration as measured both by the frequency of
ego's network contacts and by the number of material links
connecting ego and network members. This decrease was ex
pected. The focus in this chapter is on the degree to which
morphological and interactional network variables explain
tie duration decreases between ego and network members after
the move into the ACLF.


8
limited (Florida Office of Evaluation and Management Review,
1985).
The study of relocation of the elderly, a tangential
and somewhat more encompassing concept than institutional
ization per se, has been extensively studied. Yet, the bulk
of this literature has focused upon the effects of interin
stitution 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.


CHAPTER £&9£
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 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
APPENDIX
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 27 9
G FOLLOW-UP QUESTIONNAIRE ADDRESSED
TO RESIDENT'S CLOSEST OTHER 287
Vl


CHAPTER SEVEN
BETWEEN-GROUP NETWORK DIFFERENCES
In addition to analyzing the demographic and health
profile of the new residents as a whole, this analysis was
taken one step further to examine whether differences in
network characteristics could be explained by the social
structure of ego's world and/or ego's presenting health
status. An analysis of variance was done to test for sig
nificant between-group network variation.
The structural variables sex, race, and socioeconomic
status as well as indicators of ego's mental and physical
health status were the group defining variables. Each of
the structural variables were dichotomously groupedmale,
female; white, nonwhite; and private payer, state-financed.
The same approach was used for the health indicators. Men
tal health was grouped by assessed competence level, with
labels of competence or incompetence determined according to
Pfeiffer's Short Portable Mental Status Questionnaire
(1975). Physical health was grouped according to ego's
self-care capacity as determined by Katz's Activity of Daily
Living scale. If ego could perform all six activities of
daily living unassisted, he/she was considered nonfrail,
with those who needed assistance in one or more areas
considered frail.
115


Table K-4
. Variable effects on Time 2 material linkages, by focal network, unstandardized
regression coefficients
Focal Network
a
Independent Variables
Total
(N =
Primary
62)
Relative
(N = 60)
Nonrelative
(N = 31)
b
SD
b
SD
b
SD
Material links, Time 1
.39***
.12
.27**
.12
.19
.20
Density, Time 1
.01*
.00
.01*
.00
.00
.01
Degree, Time 1
.01
.03
-.04
.03
-.01
.06
Closest other intensity, Time 1
-.04
.03
.00
.03
-.01
.06
Network bondedness, Time 1
.02
.03
.03
.02
.01
.05
Reciprocity"objective," Time 1
.15
.26
.13
.30
.12
.29
Reciprocity"subjective," Time 1
.09
.19
.20
.21
-.18
.28
Sex
-.13
.15
-.12
.14
-.12
.28
Race
-.51**
.23
-.51**
.23
-.37
.47
SES
.24
.20
-.10
.21
.81**
.38
Mental health, Time 2
-.04
.06
-.04
.05
-.09
.11
Physical health, Time 2
.00
.03
-.01
.03
-.09
.11
Location, Time 2
2
-.44*
.25
-.14
.27
-.50
.50
R
.41
.35
.45
Percentage of variance by
material links, Time 1
.26
.09
.18
333


103
mean size of the supportive sector was 11, which is approxi
mately 4 greater than the average personal network size of
this sample. Given the age difference of the sample this is
a reasonable difference. The more restrictive categories of
intimates and sociables had means of 5 and 8, respectively.
Density and Degree
In terms of the density of ego's primary network, most
network members were in fairly regular contact with each
other. This finding is consistent both with Granovetter's
(1973, 1981) theory that one's network of close ties are
more likely to be bound to each other than one's network of
weak ties and with other research on the structure of in
timate networks (Cubitt, 1973; Hammer et al., 1978;
Kapferer, 1969). However, to the knowledge of this re
searcher this is the only density data to date on the net
works of the vulnerable elderly.
Not surprisingly, the relative subsector was most
tightly bound. The mean density was 89.0%, indicating that
on average 89% of the members of ego's relative network are
in fairly regular contact with each other. Nonrelative
sectors were also quite closely bound, with an average
density of 75.1%. Again, this is consistent with
Granovetter's theory. "If strong ties connect A to B and A
to C, both C and B, being similar to A are probably similar
to each other, increasing the likelihood of a friendship


Table 1-1.
Network Characteristics
Sum of Squares
Mean Square
a
F
N
Mean visiting frequency
Total
19.51
3.20
6.10*
80
Relative
49.10
3.90
12.58****
78
Nonrelative
3.46
7.19
.48
63
Mean speaking frequency
Total
4.87
2.31
2.10
80
Relative
21.08 (25.51)
2.54 (2.59)
8.31** (8.84)***
78
Nonrelative
1.89
5.28
.36
63
Mean writing frequency
Total
1.62
1.12
1.45
80
Relative
2.68
1.58
1.70
78
Nonrelative
.92
1.35
.68
63
*p < .05.
**p < .01.
***p < .005.
****p < .001.
a
DF = 4.
b
When F significant levels differ with physical health as the controlling health variable,
they are reported in parentheses.
302


207
the independent variables net of Time 1 writing levels.
This finding is consistent with results of the t-tests
reported in Chapter Ten, which indicate that unlike visiting
and speaking patterns, there is little change in network
writing patterns with ego after ACLF entry.
As indicated by the standardized beta weights (see
Table 11-2), along with Time 1 levels of total and relative
visiting and speaking, density is the best single predictor
of Time 2 total and relative visiting and speaking. This
relationship is in the predicted positive direction. The
higher the density of ego's total primary network and rela
tive subsector, the greater was ego's visiting and speaking
contact with that network at Time 2. Thus, the role of
density in the process of institutionalization is primary,
both in determining ego's level of health at the time of
ACLF entry and in determining the degree to which network
members remain in contact with ego after entry occurs.
The fact that density was not useful in explaining
nonrelative Time 2 visiting or speaking may in part be
explained by the smaller sample size available for this
analysis. Additionally, this finding lends further support
to the contention that the barriers associated with ACLF
entry are sufficient enough to negate the tie continuity
facilitating effects of ego's nonrelative network.


250
The implementation of a network support strategy neces
sitates that ACLF managers have a working knowledge of the
members of ego's primary network. This would be greatly
facilitated by a structured network assessment at the time
of ACLF entry. Good examples of these are illustrated in
Biegel, Shore, and Gordon (1984) .
As relative visiting contact does not decline during
the first six months after ACLF entry, maintaining these
relationships is a useful network support strategy for ACLF
managers. Along these lines the following tactics might be
helpful:
1. The importance of the relatives' continued
contact with new residents should be stressed.
2. Relatives should be regularly encouraged to
attend functions planned for their inclusion.
3. Relatives should be made to feel "at home"
during their visits as well as feel that
their visits were valued by residents and
staff.
4. Self-help groups directed for the significant
others of residents should be organized.
5. Relatives should be encouraged to volunteer
(or possibly be compensated indirectly by a
reduction in the resident's bill) to coordinate
activities for the residents.


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 prob
ability of professionals labeling the elderly "out of place"
in their homes. Having one's care state-financed was di
rectly related to both the probability of being profession
ally 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.
IX


183
We still feel responsible, but we're physically
unable to keep her here now. (a daughter-in-law)
I'm still very busy doing for mother.
(a daughter)
I still have to take her to the doctor's.
(a daughter-in-law)
Interactional Network Characteristics
Contact Frequency
Mean network frequency of contact scores were computed
for visiting, speaking, and writing contacts with ego at
Time 2. Additionally, visiting and speaking frequency pat
terns between ego and his/her closest other were also deter
mined due to the importance of this special relationship to
ego. As discussed in Chapter Five, the range was between no
contact in the past six months (coded 1) to daily contact in
the past six months (coded 8). In this scale, unlike in the
scale at Time 1, a response of not in the past year (coded
0) was systematically excluded. All other things being
equal, one would then expect that the mean contact at Time 2
would be slightly higher than the mean contact at Time 1.
However, paired difference t-tests revealed highly
significant decreases in both the mean total personal net
work visiting and speaking contact scores with ego since the
ACLF move. Parallel declines were revealed when ego's rela
tive and nonrelative mean contacts with ego were analyzed
for all but relative visiting. There was no significant
change in ego's average visiting contact with relatives


252
As primary network density was directly associated with
contact frequency, the coordination of intranetwork ties
also remains an important approach. This means that ACLF
managers need to make an effort both to identify ego's
primary network and then to determine how network members
can jointly function to maintain contact with ego. Along
these lines interviews revealed that contact with nonrela
tive network members was often dependent on the efforts of
relatives to transport these key others to the ACLF. Addi
tionally, network members need to know that the support they
provide to each other has a significant enhancing effect on
their relationships with ego.
A positive relationship between tie reciprocity and tie
continuity was also demonstrated. As noted earlier, reci
procity can be increased both by decreasing the number of
unreciprocated services network members need to provide for
ego and by increasing ego's ability to reciprocate to net
work members for services provided. The act of ACLF entry
is normally associated with a decrease in network responsi
bilities for ego, which could work to provide a more even
give and take in network relationships. Yet, a balance
must be sought in the need for ACLFs to provide relief for
ego's network in caring for ego and in continuing to en
courage network members to be involved in doing for ego and,
thus, to maintain some material linkages with ego.
Additionally, while the increase in ego's dependent


119
his/her network by sex, males and females did have signifi
cantly different visiting and verbal network interactional
patterns. Men had, on average, more frequent visits with
the members of their total personal network than did females
(p < .05). This relationship remained when only ego's rela
tive subsector was considered (p < .001) but was not signi
ficant when only ego's nonrelative subsector was considered.
Men also were in more frequent verbal communication with
their network, but this relationship was significant for
ego's relative subsector only (p < .01).
Once again, it was posited that this association was
due to the differential marital states of older males and
females. To this end controls were then added for marital
status. No spurious relationship was revealed. Marital
status was not significantly related to total network mean
frequency visiting and the association between sex and
visiting remained significant (p < .05).
The results of recent research on the relationship of
sex to the primary network patterns of the elderly is incon
clusive, with some authors reporting a decreased quantity or
quality of primary networks among elderly males than females
(Fisher and Oliker, 1979; Strain and Chappell, 1982), others
reporting no network differences by sex (Bogatta and Foss,
1979), and still other authors finding, as did this study,
an increased quantity or quality of primary networks among
elderly males (Ferarro and Barresi, 1982). However, none of


9
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 re
searcher 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


FOLLOW-UP QUESTIONNAIRE
ADDRESSED TO RESIDENT
Hello, my name is Mary Bear. I visited with you
approximately six months ago in regards to my study for the
University of Florida on the process by which an older
person comes to move into an ACLF. I am finishing up my
study now and have stopped by to see how you are doing at
this time. The questions I would like to ask you will take
about forty-five minutes. As before, there are no right or
wrong answers and all of your answers are confidential.
They will not be shared with your family, the staff at this
ACLF, or anyone else. Would you please give me permission
to ask you these questions?
Informed consent obtained not obtained
Date of follow-up interview
To be completed by interviewer after talking with
caregiver of ego's original residence.
Resident's name
Current address
If ego has died, prior to his/her death, did ego
(0) Remain at the original ACLF
(1) Return to his/her home
(2) Go to the home of a friend/relative
(3) Go to a nursing home
(4) Go to a hospital
(5) Other
Score from Katz Activities of Daily Living
Questionnaire (see Appendix D)
1. First, I need to recheck your memory. Proceed with the
moified Pfeiffer scale (see Appendix B).
If a score of mild impairment or above is obtained and
ego has moved, go to (2).
If a score of mild impairment or above is obtained and
ego is at the same residence, go to (9).


289
2. How are things going for ego right now?
3. Which of the following describe the reasons for ego's
move? (You can circle more than one.)
(0) Ego's health improved
(1) Ego's health worsened
(2) Ego was not happy with where he/she was
(3) Ego's friends/relatives were not happy with
where he/she was
(4) Ego/we could no longer afford the fee
(5) Other
4. How would you describe the physical care ego received
at (insert name of original ACLF)?
(0) The caregivers gave ego excellent physical
care
(1) The caregivers gave ego adequate physical
care
(2) The caregivers gave ego less than adequate
physical care
5. How would you describe the emotional atmosphere at
(insert name of original ACLF)?
(0) The caregivers seemed really to care about
ego
(1) The caregivers were pleasant, but did not
seem really to care about ego
(2) The caregivers were not pleasant and did
not seem really to care about ego
6. Which of the following best compares ego's current
physical care with that received at (insert name of
former ACLF)?
(0) The caregivers here give ego a higher level
of technical care
(1) The caregivers here give ego the same level
of technical care
(2) The caregivers here give ego a lower level
of technical care


21
types" were then categorized according to contact frequency,
tie content, and tie intimacy into five nonexclusive cate
gories: active, intimate, sociable, routine, and sup
portive. Information on personal, phone, and written con
tact 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 respon
dent 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 conceptual
ization 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


241
involvement of social workers in the management of the care
of those residents under the state program, as the role of
physicians as well as any other health professionals is
secondary.
Tie Duration and Returning Home
While "strong" network characteristics were demon
strated to have an effect on delaying ACLF entry, contrary
to the findings of Greenley (1972) and Wan and Weissert
(1981), once entry had occurred, these same network char
acteristics were not demonstrated to increase the prob
ability of ego returning home. In fact, as outlined in
Chapter Eleven, those who returned home came from networks
to which they were less emotionally bonded, and in as low a
contact with, and as materially linked to as those who
remained in the ACLF.
These findings are supportive of the theorized rela
tionship between high network bondedness, density, degree,
and reciprocity and delayed ACLF entry. If the elderly come
from one of these "stronger" networks, quite a bit of re
grouping is likely to be necessary to make it possible for
them to return home. Alternatively, while "weaker" networks
may have less regrouping to do, they may be unable to do so.
The end result would be as observed; positive network char
acteristics were not a sufficient force to increase the
elderly's probability of returning home.


CHAPTER FOUR
LITERATURE REVIEW:
NETWORK VARIABLES
AND INSTITUTIONALIZATION
A key early study that examined the influence of net
work variables on the process of mental institutionali
zation 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 chi-
square tests: (1) Patients in critical positions in their
network are hospitalized more rapidly than those in non-
critical 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 sev
erance (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 ren
dering, a conclusion which may or may not be valid.
40


142
There is a homeyness about ACLFs. . .
Nursing homes are pathetic. (a daughter-in-law)
I don't want Dad in a nursing homehe's not
at that level yet. (a daughter)
They say you don't want to put them in a nursing
home if you don't need them. (a daughter)
This negative attitude toward nursing homes was also
expressed by the the network of those who had been in a
nursing home prior to their move into the ACLF. Approxi
mately 6% of the sample fell into this category.
Interestingly, the predominant reason identified for moves
from a nursing home to an ACLF was a depletion of ego's
finances, and/or a termination of medicare coverage. Im
provement in ego's health was the second most common situa
tion.
A complete absence of remorse at leaving the nursing
home was exhibited. In fact, all of the residents and their
networks considered the move as a situational improvement.
Many were angry that nobody had "bothered" to alert them to
the ACLF alternative until after ego's money had nearly run
out. Nursing home dissatisfaction is well demonstrated in
the following comments:
The nursing home didn't care for [ego]. They
just let her sit. They didn't do anything
for her. There is no comparison with this
ACLF. It is so much better. (a daughter)
The nursing home was like a hospital ... so
regimented. . They march down the halls
to eat. . [Ego] seems much more contented
at the ACLF. (a son)


338
Dono, John E., C. M. Falbe, B. L. Kail, E. Litwak, R. H.
Sherman, and David Siegel
1979 "Primary groups in old age." Research on Aging
1:403-433.
Epstein, A. L.
1961 "The network and urban social organization."
Rhodes-Livinostone_Journal 29:129-162.
Ferraro, Kenneth
1980 "Self ratings of health among the old and old-old."
Journal of Health and_-.SP.cial Behaviai
21:377-383.
Ferraro, Kenneth, and C. Barresi
1982 "The impact of widowhood on the social relations of
older persons." Research on Aging 4:113-135.
Fillenbaum, G. G.
1979 "Social context and self-assessments of health
among the elderly." Journal of Health and
Social BgM-YiPX 20:45-51.
Fisher, C. S. and S. J. Oliker
1983 "A research note on friendship, gender, and the
life cycle." Social Forces 62:124-134.
Florida Department of Health and Rehabilitative Services
1985 "District 7 adult congregate living facilities."
Unpublished document.
Florida Office of Evaluation and Management Review
1985 "ACLF descriptive evaluation." Unpublished
document.
Fowles, Donald
1983 "The changing population." Aging 6:6-11.
Freeland, Mark, and Carol Schendler
1983 "National health expenditure growth in the 80s:
An aging population, new technologies, and
increasing competition." Health Care Financing
Royiew 4:1-58.
Freidson, Eliot
1970 Tiie_Profession of Medicine,
and Row.
New York: Harper


CHAPTER ELEVEN
NETWORK VARIABLES AS PREDICTORS OF TIE DURATION
AND RETURNING HOME
Each of the network variablesreciprocity, density,
degree, and intensitywere analyzed to determine if their
hypothesized effects on tie duration and returning home had
occurred. As in the analysis of network variables as pre
dictors of ACLF entry, ego's total personal network and
relative and nonrelative close others subsectors were consi
dered the focal networks of the analysis. Additionally,
given the importance of ego's continued contact with his/her
closest other, the effect of network variables on the dura
tion of this tie was also analyzed.
Once again, both subjective and objective measures of
reciprocity were considered, and to avoid the problem of
multicollinearity between these measures their influence on
tie duration and returning home were analyzed separately.
Similarly, the connectivity measures of density and degree
were also analyzed separately to determine their effects on
the dependent variables, minimizing any multicollinearity
effects.
Sample size was limited due to respondent death
(n = 6), respondent refusal (n = 1) and the definitional
restrictions of density and degree. The effect of this
193


100
alter substitutes used as necessary (n = 28). Both
objective measures were found to be significantly related to
ego's perceived health status in the predicted direction
with a p < .0005 (physical health) and a p < .01 (mental
health).
Morphological Network Characteristics
Appendix H presents the means and standard deviations
of the morphological characteristics of the new resident's
networks. Data were collected on the morphological vari
ables range, density and degree for both ego's total adult
primary network and primary relative and nonrelative sub
fields. As noted earlier, ego was considered the key infor
mant for this information when assessed to be mentally
competent and physically able to complete the survey. As 26
residents were incompetent at Time 1 and 4 were physically
limited, alter's responses were then substituted for approx
imately 30 surveys (two respondents with physical limi
tations were able to partially complete the survey, and
their responses were used as available). To determine the
appropriateness of this approach, paired t-tests were done
on data from alter with matching ego responses. No signifi
cant differences emerged between the two sources on any of
the network variables, substantiating the validity of this
methodology.


180
six assessed areas. Yet, recognizing that six respondents
were lost at Time 2 due to their death, and one was lost due
to significant other refusal, a paired t-test determined no
significant changes in the self-care ability of the new
residents during this six month period.
This variance was also evidenced in the respondents'
level of mental competence. Approximately two-thirds of
them were mentally competent and one-third were mentally
incompetent. Once again, no significant differences in the
new residents' level of mental competence occurred during
this six month period.
In terms of ego's perceived level of health, the
majority of the respondents felt that ego's health was
either very good (23.6%) or good (38.9%), with 27.8% of them
describing ego's level of health as fair, and only 9.7% of
them labeling it poor. However, unlike with the objective
health measures, paired t-tests revealed a significant
decrease in ego's perceived health status during this six
month period (p < .01) And, while a regression analysis
revealed that perceived health at Time 2 was related to
ego's-self care ability (p < .01) unlike at Time 1, no
relationship between ego's level of mental competence and
perceived health status was revealed at Time 2.
In tandem, these results suggest that the act of ACLF
entry does serve to redefine negatively ego's perceived


150
Similar reasoning also explains finding no relationship
between the intensity of the bond between ego and ego's
closest other and the source of ego's "out of place" label.
The intensity or strength of this one special tie is not
sufficient to keep ego's closest other or another personal
network member from perceiving ego's environmental fit as
being problematic.
While ego's closest other may share a strong, intensive
relationship with ego and, hence, have a high tolerance
level for ego's behavior, if the other personal network
members do not share this type of bond with ego, any one of
them could interject ego's "out of place" label. Ego's
closest other may also then be persuaded to perceive ego's
fit as problematic. In either case, the source of the label
is a member of ego's personal or informal network rather
than a professional. Thus, if network members are to delay
in identifying ego's fit as problematic until it is so
labeled by a professional, ego's personal network must, as a
unit, share an intense, high emotionally bonded relationship
with ego.
Although reciprocity was not a significant explanatory
variable its effect on the log odds of professional labeling
varied with the indicator used. When measured subjectively,
the relationship was in the predicted positive direction.
However, when reciprocity was measured by the proportion


APPENDIX H
MEANS AND STANDARD DEVIATIONS OF THE CHARACTERISTICS
OF NEW RESIDENT'S NETWORKS


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
December 1986
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 Congre
gate 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 measure
ment tools. A combination of multiple and logistic regres
sion and analysis of descriptive data was done.
Both network variables and the control, socioeconomic
status, were demonstrated to affect ACLF entry. The
viii


19
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 lit
erature. In general, content may be understood as that
which determines any given interpersonal link. However,
from this starting point much confusion exists in the lit
erature. Two basic directions can be followed. The first,
as outlined by Mitchell (1969), focuses on the normative
context in which interaction takes place. In 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 con
tent in terms of social exchanges. Here one speaks of links
in terms of specific behaviors, i.e., visiting and conver
sation, 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 operational
ization of the concept, content, appears to be the degree to
which researchers abstract from given behaviors to a cate
gory of behaviors to which a sociological meaning is


187
and (3) a perceived lack of privacy. This is illustrated in
the following statements:
They got to come and get me and take me to the
phone. ... It's too much work for them. (a
resident)
The phone is inconvenient. ... I've had to
wean myself away from that. (a resident)
It's not so easy to call now. . You call
and call and can't get through. . After
awhile, they stop calling. (a daughter)
In addition to the structural barriers of the ACLF,
ego's health status also frequently limited telephone
communications. As network members of hearing impaired or
cognitively impaired residents explained,
It is not possible to make sense talking with
Mother over the phone. (a son)
It is frustrating to talk to her over the
phone. . She's so hard of hearing. You
need visual aids. (a daughter-in-law)
In terms of written contact, results indicate a statis
tically significant increase in the mean frequency of com
munication between ego and his/her total personal network
after the ACLF move. Parallel increases were also demon
strated when ego's written contact with his/her relative and
nonrelative networks were analyzed. At first glance it is
tempting to conclude that when ego moved into the ACLF the
decline in speaking and visiting contact with ego and
his/her network was compensated by an increase in written
contact. However, examination of the meaning of these dif
ferent means (see Table 10-2) indicates that while there is


211
of network ties held by network members is important in
explaining tie duration after a potentially separating
event. Other studies on the network effects of help-seeking
behavior and tie duration have generally focused on density
as the indicator of network connectivity (Hammer, 1963;
Horwitz, 1977; McKinlay, 1973; Perrucci and Targ, 1982). By
clearly differentiating the explanatory power of these two
variable indicators, this study makes a useful contribution
to current network research and theory.
The finding that density and not intensity was shown to
explain contact frequency at Time 2 runs counter to "common
sense hunches" about the effect of caring on tie duration.
Rather, further support is demonstrated for the proposition
in network theory that states that it is the structural
support of one's network, i.e., the percentage of possible
intranetwork connections realized, rather than the content
of those connections that is most likely to affect the
likelihood of a relationship being maintained or severed
(Granovetter, 1973, 1981; Hammer, 1963, 1981).
Both indicators of reciprocity were found to be related
to contact frequency. Perceived balance only explained
writing, with a positive relationship emerging across all
three focal networks (p < .05). Alternatively, the rela
tionship between the "objective" measure of tie reciprocity
and contact frequency is mixed. The proportion of


28
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 im
portance 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 prob
lem. 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 prob
lem will be so labeled by a professional outside of ego's
personal network.
The intensity of ego's relationship with network mem
bers is the primary interactional variable related to la
beling behavior. The existence of intense or strong ties
implies a positive degree of emotional bondedness, instru
mental reciprocity, regularity, and duration in relation
ships. This, in turn, is likely to be related to willing
ness or sense of obligation to "do for" ego (Gouldner, 1960;


341
Kapferer, B.
1969 "Norms and the manipulation of relationships in a
work context." Pp. 181-244 in J. Clyde Mitchell
(ed.), Social Networks in Urban Situations.
Manchester: Manchester University Press.
Katz, S., A. B. Ford, R. W. Moskowitz, B.A. Jackson, and
M. w. Jaffe
1963 "Studies of illness in the agedThe index of ADL:
A standardized measure of biological and
psychological function." Journal of the American
Mg.dicaI_Association 185:914-919.
Killward, Peter D., and Russell Bernard
1976 "Informant accuracy in social network data."
Human Organization 35:269-286.
Kleh, J.
1977 "When to institutionalize the elderly."
Hospital Practice 12:121-134.
Lawton, M. Powell
1980 Environment. .an.d.-Agiflg Monterey:
Brooks/Cole Publishing Company.
1981 "Alternative housing." Journal of Gerontological
Social Work 3:61-80.
Lemert, Edwin
1951 Social Pathology; A.Systematic Approach to the
Theory of Sociopathic Behavior. New York:
McGraw-Hill Company.
Lin, Nan, Mary Woelfel, and Stephen Light
1985 "The buffering effect of social support subsequent
to an important life event." Journal of Health and
26:247-263.
Lincoln,
1982
James R.
"Intra- (and inter-) organizational networks.
Pp. 1-38 in Samuel Bacharach (ed.),
the Sociology of Organizations. Greenwich,
Connecticut: J. A. I. Press, Inc.
Liu, K.,
1983
and K. Mantn
"The length-of-stay pattern of nursing home
admissions." Medical Care 21:1211-1222.
Lowenthal-Fiske, Majorie
1964 Lives in Distress. New York: Basic Books.


25
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, multi-
plexity 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 ex
tend 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.
Granovetter1s (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


235
density and degree of ego's closest other's network is more
likely to predict the source of labeling and referral.
Consistent with Granovetter's (1973, 1981) and
Horwitz's (1977) propositions, it follows that if ego's
closest other belongs to a low density network and, thus, is
connected to a larger number of information channels, ego's
closest other will be more likely to (a) have a diverse
knowledge base and thus identify ego's condition as a prob
lem, and (b) be knowledgeable of ACLFs and, hence, refer ego
to an ACLF as a response to his/her lack of fit. Future
research in this area needs to assess the structure of the
network of ego's closest other to enable further exploration
of these propositions.
The hypothesized effect of density was demonstrated for
ego's presenting physical and mental health severity. The
greater the density of ego's total network, (a) the greater
the severity of ego's presenting mental health, and (b) the
greater the severity of ego's presenting physical health.
Relative density was directly related to ego's physical
health only. The network variablesdegree and intensity
were also demonstrated to influence ego's presenting health
status, but their effects were generally secondary to that
of density (see Chapter Nine).
The effect of density on health care utilization pat
terns has been demonstrated for other population groups
(Hammer, 1963, 1981? Horwitz, 1977; McKinlay, 1973; Perrucci


273
The second group is to include all of the adults ego
feels close to (excluding relatives and other
residents at the ACLF where ego currently lives) and
has been contact with on a fairly regular basis
during this past year. [List network in charts at
the end of the questionnaire. Record answers to (9)-
(12) in same charts. Include yourself in the
appropriate category]. Now, for each person you
identified, I am going to ask you a series of general
questions about their relationship with ego.
9a. What is the person's name?
9b. What is the basis of the relationship? (sibling,
spouse, child, friend, etc.)
9c. About how long has ego been acquainted with ( )?
Note: Score (Id), (le), and (If) in terms of times
per week, times per month or times per year.
9d. On average, about how often has ego seen ( ) during
the past year?
9e. On average, about how often has ego talked with ( )
during the past year?
9f. On average, about how often has ego exchanged letters
with ( ) during the past year?
9g. Does ( ) give ego any financial assistance?
9h. Does ( ) give ego personal assistance (i.e., rides
to the doctor, take on shopping trips, help with
laundry) when ego needs it?
9i. Does ego receive gifts from ( )?
9j. Does ego provide ( ) with any financial assistance?
9k. Does ego provide ( ) with any other personal assistance
now, or have they in the past?
91. Does ego give ( ) gifts?
10. Now, for each person you identified (including
yourself), I am going to ask you some questions
concerning how ego feels about that person. If
ego's feelings are unknown at this time answer in
terms of how ego felt the last time he/she was able
to communicate feelings to you. Please respond


151
of reciprocated links in ego's network the relationship
tended to be negative.
An explanation for this difference in effects may be
found in the more inclusiveness of the subjective measure.
As discussed in Chapter Seven, while the objective measure
addressed only material links, the subjective measure in
cluded both material and nonmaterial links between ego and
network members. Thus, if network members were highly
emotionally bonded to ego, this may carry over to result in
an overall perception of an even give and take between ego
and network members. As this latter relationship was indeed
positive, the tendency for perceived balance to be posi
tively related to labeling by a professional is consistent.
The tendency for objective reciprocity to be inversely
related to labeling by a professional is directly opposite
to what was predicted. An explanation is found in the rela
tionship between reciprocity and financial assistance. When
reciprocity is higher, ego is also less likely to be finan
cially dependent upon network members. This implies that
ego would be more likely to be able to pay for ACLF care.
Possibly, network members are more likely to recognize that
ego no longer fits when ego can afford to live elsewhere.
The lack of support for the hypothesized direct rela
tionship between the connectivity of ego's personal network
and labeling by a professional is, at least in part,
explained by the relative percentages of the differential


Table K-2Continued
Focal Network
Type of
Contact
Visiting
Time 2
Speaking
Time 2
Writing
Time 2
b
SD
b
SD
b
SD
Mental health, Time 2
-.30
.37
-.53
.31
.07
.09
Physical health, Time 2
-.31
.23
-.36*
.20
.00
.06
Location, Time 2
-1.68
1.22
-2.21**
1.07
-.01
.32
2
R
.49
.55
.59
Percentage of variance by
Time 2 contact
.31
.24
.22
Net percentage of variance
.18
.31
.37
*p
<
.10.
**p
<
.05.
***p
<
.01.
* * *p
<
.001.
* * *p
<
.0005.
a
While this table includes both connectivity, health and reciprocity measures, they were
regressed on Time 2 contact frequency separately. The reported coefficients for all
327


205
Alternatively, for ego's nonrelative sector, network vari
ables and the remaining controls explain a greater per
centage of the variance in Time 2 writing contact levels
than do Time 1 levels. Once again, both indicators of
reciprocity are the only other significant variables, but
this time the level of significance of objective reciprocity
jumps to p < .005 (see Appendix K, Table K-2).
These differences in variable effects on Time 2 contact
by type of contact and focal network are further illustrated
by examining equation differences in R-square values. As a
unit, relative network variables along with the controls
explained the highest percentage of variation in Time 2
visiting. Alternatively, for nonrelatives, the highest
percentage in the variance of contact at Time 2 was ex
plained for writing, with network variables and controls
least useful in explaining visiting.
An explanation for these results can be found in the
utilization of ACLF proximity to relatives' work sites or
homes as a primary selection criteria. While this
facilitates continued relative visiting, it limits continued
visiting by nonrelative close others. While this would not
affect telephone contact, as is discussed in Chapter Ten,
there are multiple within-site factors that serve to limit
telephone contact with ego by both relatives and nonrela
tives. Thus, nonrelatives may find it easiest to stay in


87
Measurement of Independent Variables
Three primary independent variables were identified:
(1) the connectedness of ego's primary ties, (2) the direc
tion 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
computeddensity 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 =
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 theo
retically 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


Table 1-3. Analysis of variance of network characteristics by socioeconomic status,
controlling for respondent's race, sex, and mental health
a
Network Characteristics Sum of Squares Mean Squares F N
Size
Total
6.76
16.28
.41
81
Relative
26.44
8.26
3.20
81
Nonrelative
4.97
8.11
.61
81
Size with material links
Total
10.62
11.23
.95
81
Relative
7.89
6.81
1.16
81
Nonrelative
36.19
4.90
7.39**
81
Density
Total
259.25
394.48
.66
77
Relative
26.73
213.63
.13
74
Nonrelative
264.27
604.85
.44
46
Degree
Total
1.49
6.45
.23
77
Relative
9.40
6.69
1.40
74
Nonrelative
2.89
4.47
.65
46
Mean bondedness
Total
b
103.43 (92.69)
b
8.76 (8.58)
f b
11.81**** (10.80)***
80
Relative
127.21
15.10
8.42***
78
Nonrelative
5.39
9.37
.58
63
306


336
Berger, Peter L., and Hansfried Kellner.
1981 Sociology Reinterpreted; An Essay Qn Method
and Vocation. Garden City, New York: Anchor Books.
Biegel, David, Barbara Shore, and Elizabeth Gordon
1984 Building Support Networks for the Elderly.
Beverly Hills: Sage Publications Inc.
Blau, Peter
1974 "The parameters of social structure." American
Sociological Review 39:615-635.
Blau, Peter, Carolyn Beeker, and Kevin Fitzpatrick
1984 "Intersecting social affiliations and
intermarriage." Social Forces 62:585-597.
Blau, Peter, Terry Blum, and Joseph E. Schwartz
1982 "Heterogenity and intermarriage."
Sociological Review 47:45-62.
Bogatta, E., and R. Foss
1979 "Correlates of sex among the aged."
1:517-531.
Boissevain, Jeremy
1968 "The place of nongroups in the social sciences."
ManJournal of the Anthropological Institute
of Great Britain and Ireland 3:542-556.
Borup, Jerry
1982 "The effects of varying degrees of inter-
institutional environmental change on long-term
patients." The Gerontologist 22:409-417.
Borup, Jerry, Daniel Gallego, and Pamela Heffernan
1978 Geriatric Relocation. Salt Lake City, Utah: Weber
State Press.
Bott, Elizabeth
1957
Family and Social Network
(1st
ed.) .
London:
1971
Tavistock Publications.
Family and Social Network
(2nd
ed.) .
London:
Tavistock Publications.
Brody, Elizabeth
1977 Long-Term Care for Older People. New York:
Human Services Press.


Table K-3Continued
Focal Network
^relative (N = 32)
Closest other visiting, Time 1
Closest other speaking, Time 1
Density, Time 1
Degree, Time 1
Closest other intensity, Time 1
Network bondedness, Time 1
Reciprocity"objective," Time 1
Reciprocity"subjective," Time 1
Sex
Race
SES
Mental health, Time 2
Physical health, Time 2
Location, Time 2
Marital status
2
R
Percentage of variance by Time 1 contact
Type of Contact
Closest Other
Visiting, Time 2
Closest Other
Speaking, Time 2
b SD
b SD
.17
.13




.17
.22
.02*
.01
.01
.01
.09
.11
.02
.08
-.19
.16
-.13
.12
-.11
.10
-.01
.07
2.27*****
.57
2.11*****
.42
-.42
.79
.25
.58
-.04
.55
.08
.40
1.77**
.84
.60
.62
-.96
.69
-.05
.50
.06
.24
.01
.17
-.11
.18
-.04
.16
1.58*
.83
.55
.61
1.46*
.81
-.90
.60

K>
.71
.28
.25
331


190
Table 10-3. Mean after ACLF material linkage differences
by type of network
Total
Relative
Nonrelative
(N = 71)
(N = 69)
(N = 54)
-.34**
-.34**
-.40*
*p < .0001.
**p < .0005.
Table 10-4.
Type of material links
of network (N = 72)
after ACLF
entry by type
Network
Material Link
Total Relative
Nonrelative
Dependent
4.9
4.0
.8
Reciprocal
2.3
1.8
.4
Instrumental
.1
.1
.0


226
different types of Time 2 network contact levels with ego is
not surprising (see Appendix K, Tables K-2 and K-4). Unlike
with contact frequency, net of Time 1 mean number of mate
rial links, neither network nor control variables were very
useful in explaining the mean number of network material
links with ego at Time 2. While density continued to tend
to be positively related to Time 2 level of material network
linkages, neither intensity, reciprocity, nor degree had any
explanatory value. As for the controls, while neither phy
sical or mental health status, nor sex explained Time 2
level of material linkages with ego, remaining in the ACLF
continued to tend to be negatively associated with tie
duration (p < .10). Additionally, whites and state-financed
residents maintained more material linkages with their net
work than did nonwhites and private payers.
As degree was not useful in explaining Time 2 material
links, the remainder of this analysis also focuses on the
regressions of Time 2 material links with density as the
connectivity indicator. Additionally, given that in this
instance neither reciprocity nor health indicator had
significant effects on Time 2 material links, to facilitate
comparisons between the regressions on the two different
measures of tie duration, the researcher also elected to
focus on the equations that had included mental health as
the controlling health variable and the objective measure of


27 4
with one of the following: Not at all true of
him/her (NT), somewhat true of him/her (ST), or
very true of him/her (VT).
10a. Ego can count on this person to stand by him/her.
10b. Sometimes makes ego angry or upset.
10c. Is sensitive to ego's feelings and worries.
lOd. Listens to ego's problems problems and worries.
lOe. Sometimes hurts ego's feelings.
lOf. Thinks highly of what ego knows and can do.
lOg. Sometimes makes ego discouraged.
lOh. Often cheers ego up.
lOi. Ego and ( ) see eye to eye on most things.
10j. Ego and ( ) often have trouble getting along together.
10k. Ego and ( ) get along better with each other when they
keep their feelings to themselves.
11. When you consider everything that ego shares with ( ),
i.e., personal assistance, gifts, financial
assistance, and love and companionship, would you
consider that over the long run ego gets about as
much from ( ) as ( ) gets from ego?
12. Now I am going to ask you the same series of questions
concerning how you feel about ego. (Add phrase in
parentheses if ego's mental status has been
moderately or severely impaired.)
12a. I could count on this person to stand by me (if
he/she were able).
12b. Sometimes makes me angry or upset.
12c. Is sensitive to my feelings and moods (as best as
he/she can be).
12d. Listens to my problems and worries (as best as he/she
can) .
12e. Sometimes hurts my feelings.


APPENDIX Page
H MEANS AND STANDARD DEVIATIONS
OF THE CHARACTERISTICS OF NEW
RESIDENT'S NETWORKS 296
I BETWEEN-GROUP NETWORK DIFFERENCES 300
J VARIABLE EFFECTS ON THE PROCESS
OF ACLF ENTRY 314
K VARIABLE EFFECTS ON RETURNING HOME
AND TIE DURATION 322
REFERENCES 335
BIOGRAPHICAL SKETCH 347
vii


INITIAL QUESTIONNAIRE
ADDRESSED TO RESIDENT
My name is Mary Bear. I am doing research for a
University of Florida study on the lifestyles of older
persons. More specifically, the study focuses on the
process by which older people decide to live in Adult
Congregate Living Facilities (ACLFs) and the effects of
these decisions on their family and friendship
relationships.
The purpose of this questionnaire is to obtain
information about how you decided to move to an ACLF and
how that move has affected your family and friendship
relationships. It will take about one hour. There are no
right or wrong answers. All of your answers are
confidential. They will not be shared with your family, the
staff at the ACLF, or anyone else. Will you please give me
permission to ask you these questions?
Informed consent obtained not obtained
(Only proceed if informed consent is obtained.)
1. First, I need to ask you some basic questions to check
your memory. Proceed with the modified Pfieffer scale
(see Appendix B). A score of mild impairment or above
must be obtained to proceed with the questionnaire.
2. I would like to begin with some questions regarding
your move into an ACLF. Could you briefly explain
what your living situation was like before you moved
here? (Were you living alone? With a family member?
Were you having any problems getting along? If so,
what were they?)
3. Who first suggested that you might have to move into
another living situation?
A relative
A personal contact
Your doctor, or another health professional
(i.e., nurse or a social worker)
You determined it yourself
263


166
of the deficient group made the power of the test relatively
low, any significant findings are particularly noteworthy.
While those with a deficient total and/or relative
network were not any different from those with nondeficient
networks by race or marital status (they, too, are
predominantly white and unmarried), a tendency existed for
those deficient in their total primary network to be male
(p < .08) and of lower socioeconomic status (p < .18).
Additionally, this network deficient group did not
enter the ACLF with a significantly different physical or
mental health status, and there was no difference in their
level of perceived health. As discussed by Lowenthal-Fiske
(1964), this may be explained by two opposing preentry
conditions, which in tandem would tend to result in no
significant difference: (1) if ego is with few or no signi
ficant others his/her "out of place" condition may go un
noticed until ego's health is extremely bad, and (2) if
early contact is made with formal agencies, they will have
less complimentary informal network services to work with,
thus making ego's environment less accommodating, and re
sulting in ACLF entry when ego's health is relatively
better.
In terms of the process by which the network deficient
residents came to move into the ACLF some important
differences emerged (see Tables 9-2 and 9-3). Both those
deficient in their total network (p < .01) and those


29
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 behav
ior." 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.
Thus, 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 "prob
lematic." 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.


343
National Center for Health Statistics
1981 "Characteristics of nursing home residents, health
status, and care received." National Nursing Home
Survey, United States, May-December, 1977 by
E. Hing. Vital and Health Statistics.
Series 13no. 51. DHHS Pub. No. (PHS) 81-
1712. Public Health Service. Washington: U. S.
Government Printing Office.
Neimeijer, Rudo
1973 "Some applications of the notion of density."
Pp.45-66 in Jeremy Boissevain and J. Clyde Mitchell
(eds.), Network Analysis Studies_in_Human
Interaction. The Hague: Mouton and Company.
Neugarten, Bernice
1974 "Age groups in American society and the rise of the
young old." Annals of the American Academy of
Political and Social Science 415:187-197.
Ostrom, Charles
197 8 Time Series Analysis: Regression Techniques.
Beverly Hills, California: Sage Publications Inc.
Parsons, Talcot
1968 The Structure of Social Action. New York: The
Free Press.
Pattison, E. Mansfield, Donald Defrancisco, Paul Wood,
Harold Frazier, and John Crowder
1975 "Psychosocial kinship model for family therapy."
American Journal of Psychiatry 132:1246-1250.
Perrucci, Robert, and Dena Targ
1982 "Network structure and reactions to deviance of
mental patients." Journal of Health and Social
Behavior 23:2-17.
Pfeiffer, Eric
1975 "A short portable mental status questionnaire for
the assessment of organic brain deficit in elderly
patients." Journal of the American Geriatrics
Society 23:433-441.
Rundall, Thomas, and Connie Evashwick
1982 "Social networks and help-seeking behavior among
the elderly." Research on Aging 4:205-226.


242
The controlsrace, health, and socioeconomic status
had a significant and relatively greater effect on returning
home. The effect of health was nearly triple that of any of
the other variables, indicating that while other contingen
cies (in this case being nonwhite, paying for their own
care, or having a weaker primary network) affected the
probability of the elderly going home, their health was of
primary importance in explaining this phase of the institu
tionalization process. This extends the research of
labeling theorists into a domain other than mental illness
(Goffman, 1961; Greenley, 1972; Scheff, 1966), and renders
support to the hypothesis that while the process of institu
tionalization is affected by social and cultural variables,
the "objective" health state of an individual is of more
primary importance (Gove, 1976; Gove and Fain, 1973; Gove
and Howell, 1974).
Unlike with the analysis of returning home, with the
exception of Time 1 levels of contact, the effect of con
trols on tie duration was generally secondary to that of
network variables. As with the analysis on ego's presenting
health severity, the effect of density on ego's tie duration
was primary. While the effect of density varied by focal
network and type of contact, density was positively related
to total primary and relative network visiting and speaking,
closest other visiting and speaking, and total primary and
relative material linkages at Time 2. The extensiveness of


CHAPTER TWO
NETWORK ANALYSIS
Smei;g.eiig£-aiid_DgvelQpmen.t
Network analysis may be understood as an emerging theo
retical 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
Wolfe, 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 develop
ment 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
12


52
The sample was small, consisting of only 41 SRO resi
dents. However, as the geographic area was restricted to
one hotel, a combination of participant observation and
interviewing permitted greater data accuracy. Both chi-
square 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. Fur
thermore, following previous lines of reasoning, it is prob
able 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 con
tact 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)


33
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 re
location of the elderly once they are perceived no longer to
"fit" in their current living situation is relatively prob
lematic. 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 dir
ectly related to the number of different information chan
nels 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 resolu
tion of his/her problem. On the other hand, if ego's net
work is relatively closed or dense, it is likely that this
information will be transmitted by a professional rather
than a network member.
Illness and-Illness Behavior
While often used interchangeably, the notions of ill
ness 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


45
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 institution
alization precipitant. The other counter force, number of
community service contacts, implies that institutional
ization 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 be
havior. Interviewed were 87 unskilled working class
families (this was identified as an attempt to control for
class variables), 48 of which were classified as under
utilizers 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 ser
iousness of their condition was the highest.
Information was collected about specific network fields
(i.e., kin and relatives) and about the total primary net
work (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


173
Intensity of + Severity of health
relationship with ~ ^ at time of move
Figure 9-1. Variable effects on the process of ACLF entry
Note: Race, sex, and reciprocity are omitted as they
were not significant at p < .05.
J


181
health status independently of ego's level of physical or
mental health. Hence, support is lent to the work of
labeling theorists which proposes that the act of entering
an institutionalized health care setting is a critical inci
dent serving to impute the role of illness on one's identity
(Scheff, 1966). Tobin and Lieberman (1976) also demon
strated a change in the elderly's health after entering a
long-term care facility. However, in their study nonsur
vivorship was more noteworthy, as one out of two of those
entering a home for the aged had either died or severely
deteriorated after the first year.
Msec's Response
Only a select subsample of 32 alters were contacted at
Time 2. These were the significant others who were tied to
(a) the most frail residents, those who were mentally incom
petent and/or dependent in multiple activities of daily
living (n = 27) and (b) the residents who had moved from the
ACLF and were not contactable at Time 2 (n = 5). The
majority (59%) of these significant others felt that their
lifestyles had improved either slightly or greatly since ego
had moved into the ACLF. However, a surprisingly large 37%
of alters said that there had been no change in their life
styles since ego had moved into the ACLF.
The reasons expressed for alter's lifestyle improvement
were a blend of feeling increased personal freedom along


85
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 behav
ior of members of primitive societies" (1963:917). Further
more, as observed in the Katz study, the process of rehabil
itation 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 continence, 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 alterna
tive. 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
f


113
nonrelative field, again lending support to Cantor's notion
of the neighborhood boundedness of ego's nonrelative per
sonal network.
Given that many of these vulnerable elderly have a
diminished mental capacity, the predominance of contact by
visiting may be due in part to the fact that visual cues may
be necessary to maximize meaningful communication between
ego and alter. Furthermore, while these results suggest
that ego's nonrelative sector is in relatively close prox
imity to ego, as the mean duration of ego's nonrelative ties
was 18.4 years, and approximately 16% of those ties were
known longer than 32.2 years, and given the mobility of our
society, it is unlikely that these ties can be completely
understood by limiting one's analysis to local contacts.
In terms of the relationship with ego's closest other,
the duration varied with ego's age (p < .001) and kinship
with ego (p < .001). The mean duration of ego's relation
ship with close nonrelative others was 7.2 years, while with
close relative others the mean duration was 46.7 years,
suggesting that the length of the relationship with ego's
close relatives was limited only by the age of ego and the
relative.
In conclusion, upon entering into an ACLF the average
resident is still surrounded by five relatives and three
nonrelatives to whom he/she is highly emotionally bonded.
While these relatives and nonrelatives are likely to be in


74
These strategies both maximized data quality at Time 1
and minimized the respondent drop out rate at Time 2. Al
though six of the respondents were lost to the study at
Time 2 due to their deaths, only one was lost due to respon
dent 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 respon
ses 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 recon
tacted if ego's mental or physical status prevented valid
survey completion (n = 26), if ego had moved to an out-of-
town location (n = 3), or if the family preferred that the
researcher contact them rather then ego (n = 2). The ra
tionale 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


Table
K-3. Variable
and focal
effects on Time 2 closest other contact frequency,
network, unstandardized regression coefficients
by type of
contact
Type of
Contact
Closest Other
Visiting, Time 2
Closest
Speaking,
Other
Time 2
Focal
a
Network
b SD
b
SD
Total Primary IN = £41
Closest other visiting, Time 1
. 47*****
.13


Closest other speaking, Time 1


.50****
.18
Density, Time 1
.03***
.01
.01
.01
Degree, Time 1
.04
.12
.04
.11
Closest other intensity, Time 1
.06
.14
.02
.13
Network bondedness, Time 1
-.03
.10
.00
.09
Reciprocity--"objective," Time 1
1.48**
.88
.56
.85
Reciprocity--"subjective," Time 1
.03
.64
.60
.59
Sex
.41
.51
.30
.48
Race
-.52
.79
-.61
.73
SES
-.29
.69
-.04
.64
Mental health, Time 2
-.30
.20
-.20
.18
Physical health, Time 2
-.19
.12
-.12
.11
Location, Time 2
.94
.79
.38
.75
Marital status
.14
.79
-.04
.75
z
R
.40
.24
Percentage of variance by Time 1 contact
00
CN

.19
Net percentage of variance
.12
.04
329


277
101.
Keeps
feelings
*
*
*
*
11.
Feels
balanced
*
*
*
*


134
Table 8-1. Percentage distribution of the source of the
"out of place" label and ACLF referral for new
residents
Serving
as Source of
Type of Network Member
Label
Referral
Informal members:
Relative
56.8
53.1
Nonrelative close other
3.7
8.6
Self
7.4
4.9
Formal members:
Physician
16.0
8.6
Other health professional
16.0
24.7
a
Total percentage
99.9
99.9
a
Total percentages do not equal
100.0 due to
rounding.


198
for ego to return home. Although these networks may be
willing, they may be unable to do so. Alternatively, while
"weaker" networks may have less accommodating to do, they
may be unwilling to do so. The result would be what was in
fact observed, no difference in returning home by these
indicators of network strength.
Results presented in Chapter Nine give some support for
these hypotheses as density, and significant other intensity
were directly related to the severity of ego's presenting
health (which to some degree indicates the degree of accom
modation tolerated by ego's network before ACLF entry).
Although this relationship was not consistent with degree,
network bondedness, and reciprocity, as was discussed in
Chapter Nine, this is not sufficient evidence to dispute the
proposed relationship between stronger networks and delayed
ACLF entry. Rather, these variables may be more susceptible
to the strain of caring for an aging network member. Hence,
by the time of entry, differences in these delaying forces
by ego's presenting health severity may have been erased.
In terms of the control variables, ego's health was of
central importance in explaining going home, with ego's race
and socioeconomic status also useful in explaining ego's
location at Time 2 (see Table 11-1). The more independent
ego was in the activities of daily living at Time 2, the
more likely ego was to have returned home. Similarly, all
of those who had returned home by Time 2 were assessed at


Table K-2Continu
Type of Contact
Visiting
Speaking
Writing
Time 2
Time 2
Time 2
Focal Network
b SD
b SD
b SD
2
R
.53
00

.46
Percentage of variance by
Time 1 contact
.38
.28
.35
Net percentage of variance
.15

to
o
.11
Nonrelative (N = 30)
Visiting, Time 1
.47**

to
o




Speaking, Time 1


.41
o
CN



Writing, Time 1




.36***
.11
Density, Time 1
.02
.02
.02
.02
.00
.00
Degree, Time 1
.11
.16
-.01
.14
.00
.00
Closest other intensity, Time 1
.23
.17
.15
.15
.03
.04
Network bondedness, Timel
-.03
.15
.00
.13
.04
.05
Reciprocity"objective," Time 1
-.78
.89
.29
.75
.59***
.22
Reciprocity"subjective," Time 1
-.58
.79
-.53
.63
.43**
.25
Sex
.46
.77
.76
.68
-.22
.21
Race
-1.32
1.12
-.67
.97
.33
.30
SES
1.14
.95
.98
.83
.08
.28
326


15
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 soci
ety 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 cir
cles would affect intergroup relationships in a society.
In fact, Blau's work, "Intersecting social affiliations and


185
Table 10-1. Mean after ACLF entry contact differences by
type of contract and network
Contact
Network
Total
Relative
Nonrelative
Visiting
-.75**
-.16
-.84**
(70)
(68)
(53)
Speaking
-1.21**
-.81**
-1.99**
(71)
(67)
(52)
Writing
.71*
.65*
.90*
(71)
(67)
(52)
*p < .0001.
**p < .00005.
Note: N is given
in parentheses.
Table 10-2
Before and after mean writing contact by type
of network
Total
Relative
Nonrelative
Before
After
Before
After
Before
After
(N = 78)
(N = 69)
(N = 78)
(N = 67)
(N = 63)
(N = 52)
1.06
1.66
1.30
1.83
.65
1.58


125
was measured objectively or subjectively. However, amongst
ego's nonrelative sector only, there was a difference in the
size of those with at least one material link to ego by
socioeconomic status. Those whose care was state-financed
were materially linked to a greater number of nonrelated
"close others" than those whose care was privately financed.
It is not surprising that while this nonrelative sector was
exchanging forms of assistance with ego prior to his/her
move to the ACLF, these "close others" were not willing to
extend this assistance to the point of paying for part or
all of ego's ACLF care. This finding is consistent with
that of Cantor (1979) who found very few elderly (8.5%) who
were willing to look to either friends or neighbors for
major forms of financial assistance.
Not only were the state-financed more dependent upon
their network when they entered the ACLF, they were also
less emotionally bonded to both their total primary network
(p < .005) and to their relative network (p < .005) How
ever, once again, this relationship was not found in ego's
nonrelative sector.
One can only speculate as to the pattern of
causality among these variables. It is plausible to postu
late that decreased network emotional bondedness is a conse
quence of ego's unreciprocated dependence on his or her
network and a precipitator of these networks' increased


170
Similarly, a Kendall's tau analysis indicated that there was
no educational difference between those with two or more
nonrelative "close others" and those with only one or no
close nonrelative relationships, and an analysis of variance
revealed no age differences between these two groups.
In terms of the process by which the residents came to
enter the ACLF, belonging to a deficient nonrelative network
did not make a significant difference in the source of their
label or referral, the degree to which their proposed move
was discouraged by network members, or to the degree to
which their entry was delayed after the decision to move was
made. However, while an analysis of variance indicated
that those with deficient nonrelative networks did not
enter the ACLF at significantly different levels of physical
health than did those with more than one nonrelative "close
other," nor did they perceive their level of health
any differently, those deficient in their nonrelative
network had a decreased mental health status at the time of
ACLF entry (p < .005) Thus, if a large supportive group of
nonrelative close others had acted to assist the rest of
ego's primary network in delaying his/her ACLF move, by the
time this move actually was accomplished this group had
dwindled to zero or had only one member.
In terms of the rest of their primary network, those
lacking in nonrelative significant others had not


Table K-2. Variable effects on Time 2 contact frequency, by type of contact and focal
network, unstandardized regression coefficients
Type of Contact
Visiting
Speaking
Writing
Time 2
Time 2
Time 2
a
Focal Network
b SD
b SD
b SD
Total Primary (N = £21
Visiting, Time 1
.32****
.09
Speaking, Time 1


.28**

to


Writing, Time 1




.46****
.09
Density, Time 1
.03****
.01
.02***
.01
.00
.00
Degree, Time 1
.01
.08
-.01
.08
.05
.08
Closest other intensity,
Time 1
-.01
.06
-.03
.07
.05
.04
Network bondedness, Time
1
.02
.06
.02
.07
.02
.03
Reciprocity"objective,
" Time 1
.18
.54
.15
.65
.27
.31
Reciprocity"subjective
," Time 1
.16
.38
.27
.53
.47**
.22
Sex
.11
.31
.06
.35
.12
.19
Race
-.87*
.45
-.39
.51
.13
.28
SES
.27
.40
.07
.46
.06
.23
Mental health, Time 2
-.18
.12
-.33**
.14
.00
.07
Physical health, Time 2
-.01
.07
-.04
.08
.06
.08
Location, Time 2
2
-1.24**
.53
-1.01
.61
.36
.33
R
.56
.40
.51
324


Table 1-3;
Network Characteristics
Sum of Squares
Mean Squares
a
F
N
Mean visiting frequency
Total
.20
3.20
.06
80
Relative
9.49
3.90
2.43
78
Nonrelative
4.84
7.19
.67
63
Mean speaking frequency
Total
.56
2.31
.24
80
Relative
7.05
2.54
2.78
78
Nonrelative
.90
5.28
.17
63
Mean writing frequency
Total
1.03
1.12
.93
80
Relative
.32
1.58
.20
78
Nonrelative
4.94
1.35
3.65
63
*p < .05.
**p < .01.
***p < .005.
****p< .001.
a
DF = 4.
b
When F significant levels differ with physical health as the controlling health variable,
they are reported in parentheses.
308


228
the move. Given that the strongest predictor of contact
duration is only a weak, albeit the best network predictor
of linkage duration (see Table 11-4), it follows that the
less strong network predictor of contact durationrecipro
cityis not useful in explaining linkage duration.
As for the control variables, while the finding that
nonwhites and continued ACLF residents have less material
linkages with ego at Time 2 is harmonious with previously
reported study results, the positive relationship with non-
relative material linkages and socioeconomic status is new
(p < .05). An optimistic interpretation would be that when
the state had assumed the financial responsibilities for
ego's care, ego had a more "supportive" nonrelative network.
And although nonrelatives are not normally expected to pay
for the needs of their close others, they did continue to
supplement the state service by doing for ego in other ways
after ACLF entry.
The strong effect of being nonwhite on material linkage
duration after ACLF entry again points to the greater con
tact barrier effect of the move on nonwhites than whites. In
fact, in this case the effect of race is greater than that
of density (see Table 11-4). This is especially significant
as before ACLF entry there was no objective difference in
the size of ego's network with material linkages by race.


244
The effect of reciprocity also varied by focal network
and type of contact. Furthermore, the effect of network
variables varied by tie duration indicator, with the least
restrictive indicator better explained. These results,
coupled with the qualitative data presented in Chapter Ten,
introduced another new idea to this study: Network vari
ables have their greatest effect on tie duration methods of
least resistance for that network. For relatives, visiting
contact appeared to have the least barriers; for nonrela
tives, writing contact. Additionally, "doing for" the
elderly by remaining in contact with them after ACLF was
easier than maintaining material linkages for both relative
and nonrelative primary network members.
Finally, while nonrelative network variables had no
effect on nonrelative contact at Time 2 or material linkage,
the effect of nonrelative density and nonrelative recipro
city on closest other visiting and speaking, coupled with
the qualitative data presented in Chapter Ten, lends further
support to the importance of taking into account the inter
connections between all of ego's primary network members in
theory and research on caring for the elderly and institu
tionalization of the elderly.
Practical Implications
If we adapt the stance that we must accommodate to the
health care needs of our elderly incrementally, as


APPENDIX F
FOLLOW-UP QUESTIONNAIRE
ADDRESSED TO RESIDENT


Feeding
Independent: Gets food from plate or its equivalent into
mouth (precutting of meat and preparation of food as
buttering bread are excluded from evaluation)
Dependent: Assistance in act of feeding (see above); does
not eat at all or parenteral feeding
Note: Taken from Katz (1963:915)


260
BatMng-lspQiigfi-i-filiflBfii-- or t.ubl
Independent: Assistance only in bathing a single part (as
in back or disabled extremity) or bathes self completely
Dependent: Assistance in bathing more than one part of
body; assistance in getting in or out of tub, or does not
bath self
Difissing
Independent: Gets clothes from closets and drawers; puts
on clothes, outer garments, braces; manages fasteners;
act of tying shoes is excluded
Dependent: Does not dress self or remains partly undressed
Going to Toilet
Independent: Gets to toilet; arranges clothes, cleans
organs of excretion (may manage own bedpan used at night
only and may or may not be using mechanical supports)
Dependent: Uses bedpan or commode or receives assistance
in getting to and using toilet
transfer
Independent: Moves in and out of bed independently and
moves in and out of chair independently (may or may not
be using mechanical supports)
Dependent: Assistance in moving in or out of bed and/or
chair; does not perform one or more transfers
Independent: Urination and defecation entirely self-
controlled
Dependent: Partial or total incontinence in urination or
defecation; partial or total control by enemas, catheters,
or regulated use of urinals and/or bedpans


217
were consistently significant across the different equa
tions, Time 1 closest other contact levels, as well as race,
marital status, and location all had some power in ex
plaining Time 2 closest other contact frequency.
As degree and perceived balance were not useful in ex
plaining closest other contact frequency, the remainder of
this analysis follows the strategy used in the analysis of
network contact frequency and focuses on the more powerful
regression equations, which in this case have density as the
connectivity indicator and the "objective" measure of reci
procity. Additionally, as in this analysis neither health
indicator is significant, to facilitate comparisons with the
analysis of network contact frequency, the researcher
elected to focus on the equations with mental health as the
controlling health variable. These results are presented in
Appendix K, Table K-3.
As in the analysis of the effect of network variables
on ego's network contact frequency, the effect of network
variables also varied by the social network and the type of
contact being analyzed. A comparison of the effects of
network variables on closest other contact by focal network
quantitatively substantiates some of the comments by closest
others documented in Chapter Ten on the important supportive
role played by ego's nonrelative network members. The re
gression with nonrelative network variables explained almost


Table 1-4Continued
Sum of Squares
Physical Mental
Network Characteristics Health Health
Mean bondedness
Total
Relative
Nonrelative
Bondedness to significant
other
Proportion of reciprocated
links
Total
Relative
Nonrelative
Proportion of dependent
links
Total
Relative
Nonrelative
19.45 6.46
29.73 .01
37.90 .03
2.62 79.83
.06 .07
.02 .02
.18 .10
.07 .00
.05 .04
.03 .10
a
Mean Squares F
Physical
Health
Mental
Health
Physical
Health
Mental
Health
N
8.58
8.76
2.27
.74
80
14.70
15.10
2.02
.00
78
8.72
9.37
4.35*
.00
63
36.45
35.33
.07
2.26
74
.07
.07
.90
1.02
80
.08
.08
.20
.31
78
.20
.20
.90
.49
51
.09
.09
.74
.00
80
.09
.09
.54
.40
78
.21
.21
.13
.49
51
310


Copyright 1986
by
Mary J. Bear


Table K-4Continued
Focal Network
Total Primary
(N = 62)
Relative
(N = 60)
Nonrelative
(N = 31)
Independent Variables
b SD
b SD
b SD
Net percentage of variance
.16
.27
.27
*p < .10.
**p < .05.
***p < .001.
a
While this table includes both connectivity, health, and reciprocity measures, they were
regressed on returning home separately. The reported coefficients of the remaining
variables and summary measures are from the regressions with density, the objective
measure of reciprocity, and mental health.
334


153
"real") between ego and the members of this network, and the
intensity of ego's relationship with his/her closest other
and the likelihood of ego's lack of fit being professionally
labeled were not confirmed. Rather, it is the degree to
which ego is emotionally bonded to all of his/her personal
network members and the ability or willingness of ego and/or
this network to finance ego's ACLF care that predicts the
likelihood of the informal or formal network recognizing
ego's environmental fit as a problem that needs to be
addressed.
fig.f£Er.al
The key question in this section of the analysis was,
"Did the degree and density of ego's network vary directly
with the likelihood of ego being referred to an ACLF by a
professional?" Neither network reciprocity, intensity nor
the intensity of ego's tie with his/her closest other were
hypothesized to be predictors of referral.
The hypothesized relationship between network con
nectivity and referral was not confirmed; neither the degree
nor the density of ego's total primary network, relative
subsector, and nonrelative subsector were significant pre
dictors of the change in the logit of formal referral verses
informal referral. The controls of sex and race also did
not explain the referral phase of the relocation process.
Having one's care financed by the state did continue to tend


197
health professional determining after entry that ego is not
yet ready for this level of care and then relocating ego
into ego's home or that of a relative. A lower level of
total network bondedness may also have precipitated the use
of an ACLF as a temporary caring institution in response to
an acute illness acquired by ego due to the unavailability
of network members to perform this function. Or, if ego is
relying on only a few network members to provide for his/her
needs, with other network members not caring enough to help,
the ACLF may be used to give these close others some relief.
In each of these cases, returning home would then be more
likely. These situations did occur and are discussed in
greater detail in Chapter Ten. Given the precariousness of
ego's network relationships, the assistance of a profes
sional may ease ego's transition home.
An explanation for the unconfirmed relationship between
returning home and the network variablesreciprocity, de
gree, and densityis also found in the hypothesized rela
tionship between the network variables and the process of
ACLF entry. According to network theory, along with high
network emotional bondedness and degree, high network den
sity, and high tie reciprocity function to delay ACLF entry
until ego's lack of fit is extremely problematic. Thus, if
ego comes from one of these "stronger" networks, quite a bit
of regrouping is likely to be necessary to make it possible


CHAPTER ONE
INTRODUCTION
Caring for the Elderly
Modernization has yielded many positive consequences in
the United States, as can be witnessed in the advances
demonstrated in health technology, economic technology,
literacy and mass education, and urbanization. Yet as out
lined 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 restruc
turing of the American family.
Both the absolute and relative numbers of the elderly
have increased phenomenally. At the beginning of this cen
tury, 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
1


300
Table 1-1. Analysis of variance of network characteristics by sex, controlling for
respondent's race, SES, and mental health
a
Network Characteristics
Sum of
Squares
Mean
Square
F
N
Size
b
b
i b
Total
40.68
(66.66)
16.28
(16 68)
2.50
(3.99)*
81
Relative
21.68
8.26
2.62
81
Nonrelative
4.59
8.11
.57
81
Size with material links
Total
16.05
11.23
1.43
81
Relative
15.60
6.81
2.29
81
Nonrelative
.02
4.90
.00
81
Density
Total
2424.13
(4087.82)
394.48
(433.77)
6.15*
(9.42)***
77
Relative
263.64
213.63
1.23
74
Nonrelative
1669.50
604.85
2.76
46
Degree
Total
8.26
6.45
1.28
77
Relative
.01
6.69
.00
74
Nonrelative
.00
4.47
.00
46
Mean bondedness
Total
1.02
8.76
.12
80
Relative
9.95
15.10
.66
78
Nonrelative
8.91
9.37
.95
63


164
ego's presenting health level, or the observed reversal in
bondedness.
The strain of caring for ego and the resultant declines
in network bondedness may also account for the reported
negative trend in perceived reciprocity and ego's presenting
mental health. As discussed earlier in this chapter, the
subjective measure of reciprocity contains both material and
nonmaterial linkage dimensions. Declining network bonded
ness may carry over to result in an overall perception of an
uneven give and take between ego and network members.
In conclusion, while high network density and having a
high intensity relationship with a close other did have the
effect of maintaining ego at home until his/her health
became more severe, keeping ego home had a stressful effect
on networks. This was evidenced in decreased network bond
edness with ego and lower network degree. Furthermore,
while the density of ego's total network was shown to have
the greatest total network effect on ego's presenting health
status, as a unit the characteristics of ego's nonrelative
network explain ego's presenting health status to a greater
degree than do relative or total network variables.
Network Deficient Residents
As noted earlier, the concept of network deficiency is
understood here in terms of size only, with deficiency being
defined as an "n" of less than three (including ego). The


71
confidentiality and conducting interviews in a private
setting. And, 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 face-
to-face interviews. Phone interviews were conducted due to
preference of the significant other (4) or distance of alter
from Orange County (1).


280
If a score of moderate or severe impairment is
obtained, end the interview with ego and contact
alter as per Appendix G.
2.I received your address from (insert source). How are
things going for you now?
3.Which of the following describe the reasons for your
move? (You can circle more than one.)
(0)
My health improved
(1)
My health worsened
(2)
I was not happy with
where I
was
(3)
My friends/relatives
where I was
were not
happy with
(4)
I could no longer afford the
fee
(5)
Other
4. How would you describe the physical care you received
at (insert name of original ACLF)?
(0) The caregivers gave me excellent physical
care
(1) The caregivers gave me adequate physical
care
(2) The caregivers gave me less than adequate
physical care
5. How would you describe the emotional atmosphere at
(insert name of original ACLF)?
(0) The caregivers seemed really to care about
me
(1) The caregivers were pleasant, but did not
seem really to care about me
The caregivers were not pleasant and did
not seem really to care about me
(2)


206
contact with ego by writing and relatives may find it most
convenient to visit. The differential explanatory power of
the independent variables on the different types of contact
by focal network, then, may indicate that network variables
have their greatest influence on the contact patterns of
least resistance for the network being focused upon.
With the exception of Time 1 nonrelative speaking, each
of the Time 1 contact frequency scores was significantly
related to the Time 2 level of that variable. This may be
explained, in part, by the classic problem of omitted vari
ables. As Time 1 contact levels are correlated with the
error term, the coefficient estimate of Time 1 contact
levels will reflect some of the influence of any overlooked
variables that help explain tie duration (Ostrom, 1978). As
Time 2 contact frequency levels generally were significantly
lower than Time 1 levels (see the discussion in Chapter
Ten), this indicates that the level of that decline is
predictable by the network's level of contact with ego prior
to ACLF entry. Additionally, as is indicated in Appendix K,
Table K-2, Time 1 contact frequency levels explained a
relatively high percentage of the variability in Time 2
contact frequency.
As mentioned earlier, this was especially true for the
effect of Time 1 total and relative writing on Time 2
writing levels. Only approximately 9% of total Time 2
writing and 11% of relative Time 2 writing were explained by


133
for both the labeling and referral process. Thus, these
responses were considered as primary data sources, with
information from ego substituted when alter responses were
missing. As only six alters were not interviewed, any
substitution effect should be minimal.
The distribution of the types of network members attri
buted with the labeling and referral of new residents is
illustrated in Table 8-1. Information on the relative con
tribution of both the aggregated categories, formal and
informal, as well as the subcategories of self, relative,
nonrelative personal network member, physician, and other
health professional, in the process of ACLF relocation is
outlined. These results show the importance of the informal
network in both the labeling and referral process. Over
two-thirds of the respondents had their lack of fit identi
fied by an informal network member, and approximately the
same percentage identified the informal network as the
source of ACLF referral. Furthermore, it seems that the
informal network did little to discourage ego from moving
once the labeling and referral process had occurred, as only
2.5% of the respondents admitted to having either friends or
relatives trying to discourage them from moving into the
ACLF.
Within this informal network, relatives were identified
as playing the primary role for both phases of entry, with
over 50% of the total labelings and referrals attributed to


34
or normal acts or attributes for a given individual. Alter
natively, illness behavior is the response of a given indi
vidual 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 par
ticular 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 relation
ship. 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.


Table 1-4Continued
Network Characteristics
Sum of Squares
Mean Squares
a
F
N
Physical
Health
Mental
Health
Physical
Health
Mental
Health
Physical
Health
Mental
Health
Mean writing frequency
Total
1.60
4.48
1.15
1.12
1.38
4.02*
80
Relative
3.36
7.50
1.63
1.58
2.06
4.76*
78
Nonrelative
.00
.47
1.36
1.35
.00
.35
63
*p < .05.
**p < .001.
a
DF = 4.
312


72
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 as
sessed at the onset of the interview (after obtaining in
formed 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 question, "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 func
tioning 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 port
ability (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, ori
entation 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 educa
tion and race influenced performance, they are adjusted for
in score evaluation. Scores are then coded into four dis
tinct levels of intellectual functioning: intact


264
4. In general, how were you feeling at that time?
Very good
Good
Fair
Poor
5. Who first suggested that moving into an ACLF might be a
good idea?
A relative
A personal contact
Your doctor or another health professional
(i.e., a nurse or a social worker)
You determined it yourself
6. Could you briefly explain how you felt about moving to
an ACLF? (Was it a last alternative? Preferred over
going to a nursing home? Resisted at all costs? The
best available option?)
7. Did any of your relatives or personal contacts
discourage you from moving to an ACLF?
Yes
No
8. Once you decided to move to an ACLF, was your move
delayed due to
Lack of space in the ACLF of your choice
Financial problems
Difficulties in selling your home or other
possessions
Other
No delays were experienced
9. Which of the following describes how you pay for your
care at this ACLF?
I pay for my care myself
My family pays for my care
The state of Florida pays for my care
Other
10.Now I would like you to identify two groups of people.
In the first group, will you please include all of the
relatives that you have been in contact with on a
fairly regular basis in the past year. (By a contact,
I mean either a phone call, a letter, or a visit).


62
Scheff's study (1966) 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 respon
sible for patient care were surveyed for information regard
ing 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 pat
tern of deinstitutionalization within Rhode Island's nursing
home system also supports the effect of "external contingen
cies" on deinstitutionalization. In spite of an elaborate
system operating to assess the appropriateness of medicaid-
supported 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 in
triguing 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.


104
once they have met" (Granovetter, 1973:1362). As the mean
duration of ego's friendship ties was 18.4 years, C and B
have had plenty of time to become acquainted with each
other.
There was a higher probability of any two members in
the subsectors being linked than in the total network.
Thus, while ego's subsectors were quite dense, the density
of his/her total network was a relatively low 65.8%. Yet,
this finding is still quite high and should not be taken to
indicate that these total primary networks are not intercon
nected.
As noted earlier, another way to measure a network's
interpersonal mesh is by calculating the degree or mean
number of relations network members have with each other.
Unlike the density figure, as the size of the network in
creases, the potential degree will increase. Therefore, if
two networks have relatively the same densities, the larger
network will have the higher degree. In this case, the
larger the network, the larger was the degree. The mean
number of relationships between any one member and the other
network members was 5.0 for the total primary network, 4.6
for the relative network subsector, and 3.7 for the nonrela
tive subsector.


275
12f. Thinks highly of what I know and can do.
12g. Sometimes makes me discouraged.
12h. Often cheers me up.
12i. We see eye to eye on most things (or used to when ego
was feeling better).
12j. We often have trouble getting along together.
12k. We really enjoy spending time together.
121. We get along better with each other when we keep our
feelings to ourselves.
13. How old is ego?
60-64
65-69
70-74
75-79
80 +
14. List each of ego's network members in a random pattern
on a blank sheet of paper. Assist the respondent in
connecting each of these members who are currently in
fairly regular contact with each other. Identify the
relationship with ego as relative (R) or nonrelative
close other (NR).


154
to increase the probability of professional involvement in
the relocation process. However, this relationship only was
significant in the analysis of ego's nonrelative sector (see
Appendix J, Table J-2).
A reason for the lack of support for the hypothesized
direct relationship between network connectivity and refer
ral by a professional is also found in the relative percen
tages of the differential sources for ego's ACLF referral
(see Table 8-1). As ego's primary network is the principal
ACLF referral source, with ego only rarely the source of
this decision, the focal network for studying this process
was not appropriate. Rather than consider ego as the net
work anchor, the network of ego's closest other (who is
ego's most important primary network member) is most likely
to predict who suggested that ego move into an ACLF.
Consistent with Granovetter's (1973, 1981) and
Horwitz's (1977) proposition, one would deduce that if ego's
closest other belongs to a low-density network and, thus, is
connected to a larger number of information channels, the
closest other will be more likely to be knowledgeable about
ACLFs and, hence, to refer ego to an ACLF as a response to
his/her lack of fit. Alternatively, if ego's closest other
belongs to a high-density network his/her knowledge base
will be more encapsulated. It is then less likely that the
closest other will be informed of ACLFs as a possible alter
native living arrangement for ego and, hence, consider


58
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 non
resident friends and family, and staff relationships engaged
in by the resident was associated with successful readjust
ment to relocation in terms of life satisfaction and physi
cal 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.


23
upon the direction of the interaction, the tie is asym
metric, 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 contin
gent 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 inti
macy is shared between parties, their efforts to maintain
the relationship will be greater than if intimacy is only


201
combination of network connectivity and normative pressure
as indicated by nonwhites was a significant predictor of
returning home.
While the effect of socioeconomic status on returning
home was only significant in the analysis of the effect of
ego's total network on returning home, the trend did remain
in the regression of relative network variables. Private
payers were more likely to return home than those whose care
was financed by the state. This finding indicates that,
while ego's socioeconomic status was not related to ego's
presenting health status, controlling for ego's health, and
social network variables, money still remains an important
factor explaining the process of institutionalizing the
elderly. When either ego or ego's network was paying for
ego's care, ego was more likely to return home.
In conclusion, if ego were highly emotionally bonded to
his/her network at the time of the move into the ACLF, and
ego is white, of poorer health status, and has arranged to
have his/her care financed by the state, then ego is more
likely to remain in an institutionalized setting after ACLF
entry has occurred. Alternatively, those residents who are
most likely to return home are in better physical and mental
health, nonwhite, have been paying for their care them
selves, or with the help of their network, and were less
emotionally bonded to their network at the time of ACLF


46
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, util
izers 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 differ
ences 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.


225
extra contact barriers they may be faced with and continue
to be in more visiting contact with the resident than
whites, as they were before ACLF entry.
Location also explained contact frequency, with those
who remained in an institution in tending to be in more
contact with their closest other than those who returned
home (p < .10) This relationship was contrary to what was
expected. Yet, it does support other study results that
point toward weakness in the networks of those returning
home. As this result was present in the analysis of rela
tive as well as nonrelative variables its effect is more
generalizable than the findings on race and marital status.
M£gxj.al_Link£
The alternative indicator, network material linkages at
Time 2, was also used to analyze changes in tie duration
after ACLF entry. This approach focuses on the maintenance
of tie content rather than on the frequency of interaction
between ego and network members. As it is generally more
difficult for network members to continue to exchange ser
vices with ego than for them to remain in contact with ego,
Time 2 material linkages is a more restrictive measure of
tie duration.
Thus, finding that the proportion of variance in Time 2
material links explained by the regression analysis was
generally less than that explained by the regression of the


246
As the network variables density, reciprocity, and
intensity were demonstrated to be directly related to the
severity of ego's presenting health, it follows that strate
gies oriented to delaying ACLF entry should focus on
strengthening these characteristics of ego's primary net
work. After identifying ego's primary network, intranetwork
density may be increased by working with ego and network
members to develop a cohesive plan to meet ego's affective
and instrumental needs. This would serve to make network
members aware of each other's roles and help them to work
together more efficiently and effectively.
The proportion of reciprocal links can be increased
both directly and indirectly. Indirectly, an increase can
be attained by providing more professional home care ser
vices, decreasing ego's dependency on network members. If
an improvement in ego's health is a consequence of these
services, a direct increase in ego's ability to reciprocate
may result. As the data indicated that only 15% of the
residents had been receiving formal support services before
ACLF entry, much room for improvement in this area exists.
By increasing intranetwork linkages and decreasing the
service demands for network members, professionals will
facilitate network accommodation to ego's needs and delay
ACLF entry. These actions may also stabilize the emotional
bondedness ego's network has with ego, as results indicated
that unlike the relationship with ego's closest other, the


Table 11-3. Variable effects on closest other visiting at Time 2, by focal network,
standardized regression coefficients
Focal Network
Variable Name
Closest other visiting, Time 1
Density, Time 1
Closest other intensity, Time 1
Network bondedness, Time 1
Reciprocity"objective," Time 1
Sex
Race
SES
Total Primary
(N = 64)
Relative
(N = 61)
Nonrelative
(N = 32)
B
SD
B
SD
B
SD
.51****
.13
.50****
.14
.18
.13
.30***
.01
.28***
.01
.22*
.01
.09
.14
-.01
.13
-.26
.16
-.05
.10
-.12
.07
-.18
.10
.22**
.88
.25**
.92
.52****
.57
.10
.51
.01
.47
-.01
.55
i
.
o
VO
.79
.01
.77
.32**
.84
-.06
.69
-.19
.68
-.20
.69
-.19
.20
CO
o
.
1
.19
-.04
.24
Mental health, Time 2
220


7
Although ACLF living with its official rules and regu
lations and presenting accommodations of group life is gen
erally 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 lib
eral 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.
Theoretical Gaps
Given the continuing need among the elderly for insti
tutionalized care and the potential attractiveness of ACLF
living as an alternative for those elderly who do not re
quire 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 institu
tionalization 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


120
these works focused on ego's relationship with his/her pri
mary network as a unit, thus overlooking such concepts as
density and degree in their analysis. Rather, they focused
on the interaction network characteristics of intensity and
contact frequency between ego and specific ties. This dis
sertation, then, gives a new perspective to the research on
social networks and the elderly.
Differences by Race
Controlling for ego's sex, socioeconomic status, and
health (both physical and mental), five network variables
were associated with ego's race: density, degree, bondedness
to ego, frequency of contact, and perceived tie reciprocity.
There was no significant difference between whites and non
whites in terms of the size of ego's personal network; the
size of the subset of that network that was also materially
linked to ego, or in the objectively determined direction of
their network ties (see Appendix I, Table 1-2).
Both a higher percentage of possible links were actual
ized (density) in the total personal networks of nonwhite
new residents (p < .05) and network members had a higher
average number of intranetwork linkages, or degree
(p < .05). When ego's subnetworks were analyzed, a slightly
different picture emerged. Only the density of the relative
subsector (p < .05) and only the degree of the nonrelative
subsector (p < .05) were significantly higher for nonwhites.


126
tendency to relinquish the financial responsibility for
ego's care to the state.
While ego's financial resources influenced the degree
to which ego was able to "repay" assistance from his or her
network, ego's financial resources were not associated with
the degree to which ego's assistance to his or her network
was "repaid" by the network. Private payers did not have a
significantly greater proportion of instrumental links with
their network than did state-financed residents. As instru
mental links occurred primarily when assistance rendered
earlier by ego to one of his or her children was not cur
rently being "repaid," these results indicate that ego's
financial resources were not associated with the degree to
which ego's children were providing assistance to ego. Pos
sibly this may be explained by an overriding effect of ego's
geographic proximity to his or her children. Yet, as mat
erial links could include money or gifts (neither of which
are limited by distance) geographical distance is not a
sufficient explanatory factor. More likely, the degree to
which ego's children provide assistance to ego is associated
with their attitude toward ego. And, if this is the key
causal factor, this pattern of material linkages will be
highly resistant to change.


90
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 sym
metry, 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 (substi
tute 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


Table K-2<
three focal networks are from the equations with density, as degree was not significant.
The health and reciprocity indicators for the equation varied due to differences in
significance. Physical health was used for the nonrelative network and mental health was
used for the relative and total network analysis. Perceived balance was used for total
and relative writing, with the objective measure of reciprocity used in the other
equations.
328


CHAPTER SIX
THE PARTICIPANTS: THE NEW RESIDENTS
Presenting Demographic and. Health-Profile
While there was considerable variation among the new
residents in terms of their functional ability and mental
capacity, a typical demographic profile did emerge. Of the
81 residents included in the study, the majority were unmar
ried (87.6%), white (85.%), female (69.1%), aged 80 years
and older (54.3%), and were either paying for their care
themselves (61.7%) or with the help of their families
(18.5%). In terms of education, however, no typical pattern
was presented: 37.5% had less than a high school education;
32% had at least some high school education; and 30% had
more than a high school education.
This picture is similar to the one described in the
1985 report by Florida's Office of Evaluation and Management
Review which randomly sampled from all ACLF residents
throughout the state. Of those 60 and older in that sample,
the majority were female (73%) white (94%), and unmarried
(81%). The average age of all the residents (including
those under 60) was 79, with 91% of them over age 60. Four
teen percent of that total sample's care (including those
97


48
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 treat
ment, 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 associ
ation 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,


127
Health-Related Differences
Controlling for the structural variables race, socio
economic status, and sex, four characteristics of ego's
personal network varied significantly with ego's health
status: density, network bondedness to ego, the average
frequency of network member's written and visiting contacts
with ego, and the proportion of instrumental links. Neither
ego's physical nor mental health was related to ego's net
work size, degree, proportion of reciprocated or dependent
links, perceived proportion of balanced network relation
ships, or the mean verbal communication with ego by network
members (see Appendix I, Table 1-4).
The density of ego's total network was inversely re
lated to both ego's level of competence or mental ability
(p < .0001) and to ego's self-care ability at the time of
his/her move into the ACLF (p < .05). However, when the
relative and nonrelative subsectors were analyzed separ
ately, this relationship was not significant. Thus, it was
the manner in which these subsectors related; i.e., the
percentage of possible links that were actualized in ego's
total primary network, that was associated with ego's health
at the time of his/her move into the ACLF.
The reasons for this association are postulated in the
multiple consequences of network density on the reaction of
ego's network to ego's person-environmental fit. First,
given that network density is indirectly related to the


276
NETWORK CHART
9a. Name
*
*
*
*
9b. Tie basis
*
*
*
*
9c. How long known
*
*
*
*
9d. Seen
*
*
*
*
9e. Spoken with
*
*
*
*
9f. Letters
*
*
*
*
9g. Receives money
*
*
*
*
9h. Receives help
*
*
*
*
9i. Receives gifts
*
*
*
*
9j. Provides money
*
*
*
*
9k. Provides help
*
*
*
*
91. Provides gifts
*
*
*
*
10a. Counts on
*
*
*
*
10b. Angry
*
*
*
*
10. Sensitive
*
*
*
*
lOd. Listens
*
*
*
*
lOe. Hurts feelings
*
*
*
*
lOf. Thinks highly
*
*
*
*
lOg. Discourages
*
*
*
*
lOh. Cheers up
*
*
*
*
lOi. Eye to eye
*
*
*
*
10j. Trouble
*
*
*
*
10k. Enjoys time
*
*
*
*


47
Horwitz (1977) also examined the relationship of net
work variables to the help-seeking process. Labeling, re
ferral, 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 clas
ses III and IVthe 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 indi
cator 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, ab
breviated friendship network. Testing was done via multiple
regression analysis, with categorical independent variables
treated as dummy variables.


Table 11-2. Effects of ego's total and relative network on visiting and speaking contact
after ACLF entry, standardized regression coefficients
Total Network Relative Network
(N = 62)
(N = 60)
Visiting Speaking
Visiting Speaking
Variable Name
B
SD
B
SD
B
SD
B
SD
Visiting, Time 1
# 39****
.09


#45****
.10


Speaking, Time 1


.31**
.12


.56****
.12
Density, Time 1
.43****
.01
.32***
.01
.25**
.01
.22**
.01
Closest other
intensity, Time 1
-.03
.06
-.05
.07
-.02
.07
-.11
.07
Network bondedness,
Time 1
.05
.06
.04
.07
-.20
.05
-.21
.05
Reciprocity
"objective," Time 1
.03
.54
.03
.65
.23**
r-~
vo

.20*
.60
Sex
.03
.31
.02
.35
-.12
.35
-.03
.31
Race
-.21*
.45
-.10
.51
-.04
.53
.00
.47
Socioeconomic status
.07
.40
.02
.46
-.11
.49
-.18
.44
208


32
Once illness is recognized, the potential ACLF resi
dent's illness behaviors may be organized in a highly vari
able 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 ser
vices." 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." However, it is also possible that the physi
cian'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


APPENDIX B
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE


20
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 ade
quacy." However, they also avoid any conceptualization of
exchange relationships.
This is not to say that an exchange framework invari
ably prevents conceptualization of behavior. It is possible
to begin one's research by identifying these specific inter
personal 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 relation
ships. 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 fol
low-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


196
connectivity or the directionality of network ties at Time 1
and relocation regardless of the indicator used.
The higher the intensity, i.e., the emotional bonded
ness, of ego's ties with his/her total personal network at
the time of the move into the ACLF the lower was the likeli
hood of ego returning home by Time 2 (p < .05). However,
this relationship did not remain significant when ego's
relative network was analyzed. Thus, once again, it is the
way ego's network functions as a unit that is important in
explaining the process of moving into an ACLF.
As these results emerged controlling for ego's physical
health at Time 2, they indicate that given residents are of
the same self-help level, those that are less emotionally
bonded to their networks are more likely to return home.
This is contrary to what was predicted, and is in opposition
to the findings of Allison-Cooke (1982), Greenley (1972) ,
and Wan and Weissert (1981) (see Chapter Four). However, an
explanation may be found in network theory. Given that high
network emotional bondedness to ego functions to delay ego's
move into the ACLF until ego's environmental fit is ex
tremely problematic, if ego is highly bonded to all of
his/her primary network members, once ego does move into an
ACLF it is likely that ego will not return home.
Alternatively, if ego is not highly emotionally bonded
to all of his/her primary network members, ACLF entry may
have been premature, with ego, a caring network member, or a


179
You call this a life? There is no lifestyle
here. It's deadly here. We came here because
our daughter wanted us to, but we miss our
friends in Sun City. (a resident couple)
Insufficient activity, and the inaccessibility of both a
telephone and public transportation were also perceived as
negative consequences of an ACLF lifestyle. Thus, as in
Arling, Harkins, and Capitman (1986), and Ryden (1984, 1985)
for some of the new residents ACLF entry was found to be
associated with a loss of personal freedom and control,
which then contributed to an over-all decrease in morale.
Ego's Health
Data on the resident's self-care ability, mental compe
tence, and perceived health were also attained at Time 2.
As at Time 1, ego's self-care ability was determined by
interviewing ego's current caregiver; his/her mental compe
tence level was determined by administering Pfeiffer's
Short Portable Mental Status Questionnaire; and ego's per
ceived level of health was attained by asking residents to
describe their overall health at this time. For this latter
measure alter substitutes were used when necessary due to
ego's unavailability or mental incompetence.
Six months after the ACLF move, there remained a wide
variance in the respondents' level of independence in their
activities of daily living. While 44.6% were independent in
all of their activities of daily living, 34% were dependent
in at least two functions, and 3.7% were dependent in all


346
Wellman, Barry
1981 "Studying personal communities." Pp. 61-81 in Peter
Marsden and Nan Lin (eds.), Social Structure and
Social Networks. Beverly Hills, California:
Sage Publications Inc.
Wells, Lilian, and Grant MacDonald
1981 "Interpersonal networks and post-relocation
adjustment of the elderly." The Gerontologist
21:177-183.
Wentowski, Gloria
1981 "Reciprocity and the coping strategies of older
people: Cultural dimensions of network building."
The Gerontologist 21:600-609.
Wheeldon, P.D.
1969 "The operation of voluntary associations and
personal networks in the political processes of an
inter-ethnic community." Pp. 124-180 in J. Clyde
Mitchell (ed.), Social Networks in Urban
Situations. Manchester: Manchester University.
Whitten, Norman, and Alvin Wolfe
1973 "Network analysis." Pp. 717-746 in John J.
Honigmann (ed.), Handbook Of S O 0 i a 1_ an,d_Cultuxal
Gerontology. Chicago: Rand McNally Publishing Company.
Wolff, Kurt H. (ed.)
1950 The Sociology of Georg Simmel. New York: The
Free Press.
Wylie, F. M.
1971 "Attitudes toward aging and the aged among black
Americans: Some historical perspectives." Aging
and Human Development 2:66-70.


SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE
1. What is the date today?
Month Day Year
2. What day of the week is it?
3. What is the name of this place?
4. In which room do you live?
5. How old are you?
6. When were you born?
7. Who is the president of the U.S. now?
8. Who was president just before him?
9. What was your mother's maiden name?
10.Subtract 3 from 20 and keep subtracting 3 from each
new number all the way down.
Total number of errors
To be completed by interviewer:
Resident's name: Date:
Sex: 1. Male Race: 1. White
2. Female 2. Black
3. Other
Years of education: 1. Grade school
2. High school
3. Beyond high school
Eote: This tool is adapted for an Adult Congregate Living
population from Pfeiffer's 1975 questionnaire.
257


243
these findings coupled with the resultant nonexplanatory
power of intensity and degree lends significant support to a
hypothesis that is central both in this study and in network
theory: It is the density of one's network, i.e., the
percentage of possible intranetwork connections realized,
that is most likely to affect the likelihood of a relation
ship being maintained or severed (Granovetter, 1973, 1981;
Hammer, 1963, 1981).
The hypothesized relationship between reciprocity and
tie duration was also confirmed: The greater the degree of
reciprocity characterizing the elderly's network relation
ships at the time of ACLF entry, the more likely those
relationships were to endure. These results are supportive
of the work of Gouldner (1960) Horowitz and Shindelman
(1983), and Wentowski (1981). According to the theorized
effect of reciprocity on tie linkages, two primary reasons
people "do for" others are to return past services and to
obligate the recipient for future assistance. Thus, these
findings suggest that when the elderly had been able to
maintain a relatively high degree of balance in their rela
tionships prior to ACLF entry, that network members may not
yet feel that they have already "repaid" the new resident
for services rendered in the past and hence expended the
required effort to continue to "do for" them by remaining in
contact with them.


Ill
Frequency and Duration
Frequency and duration were also computed in terms of
network means. Summary statistics are presented in Table
6-2. Comparisons across network groups indicate that there
was a higher reported frequency of visiting and speaking
contact and a lower frequency of written contact between ego
and his/her nonrelative sector than between ego and his/her
relative sector at Time 1. These results are compatible
with those of Chappell (1983), who notes that in her study
of over 400 elderly Canadians, face-to-face contact with
close friends is more frequent than with relatives living
outside the household. In tandem, this suggests that while
at least part of ego's relative network is most likely
geographically dispersed, nonrelative network members are
more likely to be neighborhood bound. Similar results were
reported by Cantor (1979).
Comparisons across type of contact indicate that
speaking was the most common means of contact in both rela
tive and nonrelative sectors. But, given that this category
included telephone as well as face-to-face conversations the
difference between speaking and visiting was interestingly
small. This was especially so in the nonrelative sector.
It seems that most of these people are primarily in face-to-
face contact with ego. Writing was quite rare in both
sectors, but once again this was especially so in the


247
strain of caring for ego at home tends to lower the over all
bondedness ego has with network members as a unit.
In terms of ego's relationship with his/her closest
other, efforts should be directed at support and enhance
ment. Self-help groups organized for these primary care
givers might be useful as may the provision of respite care.
A similar strategy should be used with nonrelative primary
group members, as the combined characteristics of this sub
sector were demonstrated to have the greatest effect on
ego's presenting health severity.
Thus, this researcher advocates, as do Biegel, Shore,
and Gordon (1984), that because most elderly do have a
network of concerned others, health professionals should
also focus on this network when developing strategies for
assisting the frail elderly to remain in their homes. While
these strategies will work to prevent unnecessary ACLF
entry, different variables need modification to assure ac
cess to ACLFs when their services are needed. Central among
these is educating both the public and health professionals
of the nature of this type of care facility. Although the
small role of the residents in self-labeling and referral is
in part accounted for by their degree of infirmity at the
time of these decisions, their lack of knowledge of ACLFs
can not be discounted. The low involvement of physicians
and absolute uninvolvement of nurses in this decision-making


59
A breadth of consequences were studied, including the
effects of forced relocation on the resident's life satis
faction, 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.
(1973:172)
Furthermore, in a later article (1982), when Borup reexam
ined these effects in terms of the degree of environmental
change experienced by the residents, even those residents
experiencing the most radical environmental changes wit
nessed 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 fa
milial 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


297
Appendix hContinued
Network Characteristics Mean SD N
Number of instrumental
linkages
Total personal network
.83
1.53
81
Relative network
.77
1.42
81
Nonrelative network
.22
1.34
81
Ratio of ties with material
linkages to total ties
(percentage)
Total personal network
80.08%
24.78
80
Relative network
87.41%
19.65
78
Nonrelative network
62.45%
44.28
63
Ratio of reciprocal links to
total links (percentage)
Total personal network
52.28%
29.68
80
Relative network
56.54%
28.61
78
Nonrelative network
50.01%
45.03
51
Ratio of dependent links to
total links (percentage)
Total personal network
Relative network
Nonrelative network
Ratio of instrumental links
to total links (percentage)
Total personal network
Relative network
Nonrelative network
38.45% 31.24 80
33.68% 31.24 78
46 .38% 45 .38 51
8.22% 16.13 80
9.78% 18.12 78
13.36% 77.97 51
Ratio of perceived equivalent
ties to total ties
(percentage)
Total personal network
73.01%
59.54
79
Relative network
67.49%
39.24
77
Nonrelative network
68.81%
45.14
49


186
supportive efforts toward the relatives of ego, who were
then expected to maintain the direct material and non
material links with ego. This is demonstrated in the fol
lowing comment by the wife of a network member:
She doesn't see . real often, but she helps me.
... We go out to dinner every Sunday after church.
ACLF entry had a greater effect on continued network
speaking contact than visiting, as demonstrated by the over
50% greater drop in mean speaking over mean visiting.
Additionally, unlike Time 2 visiting, the demonstrated de
cline in ego's speaking contact with network members was
also shown to occur with ego's relatives. As the speaking
category included both visiting and telephone conversations,
a rationale for a these differences must be found in ego's
telephone communications with relatives.
Telephone contact appeared to be limited to a great
deal due to the structure of the ACLF, exemplifying what
Goffman (1961) has identified as the low permeability of
institutions. It was rare for a resident to have his/her
own phone or to share a phone with a roommate. Rather,
resident telephone access was typically limited to a cen
trally located community phone at the ACLF which acted to
limit utilization due to (1) limited mobility of the resi
dent, (2) hesitancy of the resident to tie up the phone and
limit business related calls or calls to other residents,


82
dition 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" (2), "you determined it yourself" (3), and
"another health professional" (4). These were then aggre
gated 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


83
examination (between 60 days prior to admission and 30 days
after admission) of the resident. However, unless the exam
ination 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 resi
dent'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 physi
cian 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 inter
views with ego and alter, and a self-care index which was
derived from Katz's Activities of Daily Living (ADL) Ques
tionnaire (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 al
ready 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


291
(6)
Ego is in a nursing home
(7)
Ego is in a hospital, but plans to return to
the ACLF
(8)
Ego is in a hospital and does not plan to
return to an ACLF
(9)
Ego is in same ACLF
(10)
Ego is in new ACLF
Which of
the following best describes
ego's current
"fit" with his/her living situation?
(0)
Very good
(1)
Good
(2)
Fair
(3)
Poor
At this
health?
time, how would you describe
ego's overall
(0)
Very good
(1)
Good
(2)
Fair
(3)
Poor
Since I
first saw you, would you say
that ego's overall
health has
(0)
Improved greatly
(1)
Improved slightly
(2)
Stayed the same
(3)
Declined slightly
(4)
Declined greatly
16. Since I first spoke with you, would you say that ego's
lifestyle has
(0) Improved greatly
(1) Improved slightly
(2) Stayed the same
(3) Declined slightly
(4) Declined greatly
17. Since I first spoke with you, would you say that your
overall lifestyle has
(0) Improved greatly
(1) Improved slightly
(2) Stayed the same
(3) Declined slightly
(4) Declined greatly


138
8-2). This supportive role was primarily held by relatives
with official agencies remaining on the periphery. In fact,
while nearly half of the new residents had been living with
relatives and an additional 31% of them had been receiving
assistance from relatives while remaining in their own
homes, less than 15% had been receiving any formal support
services just prior to their move.
The reason for the low involvement of formal agencies
is unclear from these data. As this portion of the inter
view emphasized the situation just prior to ACLF entry, it
is possible that formal agencies had assisted with ego's
needs earlier, thus boosting these agencies actual per
centage of involvement. Yet, as informal network members
were also ego's primary labeling and referral sources, it is
likely that these results simply underscore the relatively
high degree of noninvolvement by formal agencies in the
process of ACLF entry for the majority of the new residents.
As a more extensive utilization of formal services may have
worked to prolong the stay of some of the new residents in
the community the reasons for these findings need to be ex
plored further.
Critical incidents commonly surfaced as key contribu
tors to the decision to relocate ego, or, alter talked at


245
advocated by Streib et al. (1984), results from this study
suggest that ACLFs hold promise of being an exemplary
within-system change addressed to these demands. However,
this is not to imply that ACLFs are a near-perfect phenom
enon. Direction for improvement also emerged from the
analysis of data from new residents and key members of their
networks.
Le a t e g i on
A principal goal of any health care service is that it
be optimally utilized. Both under- and overutilization are
to be avoided. This necessitates that any given service be
accessible and available as well as that options compli
menting that service be accessible and available.
In terms of ACLF entry, results suggest that the goal
of optimal utilization has yet to be reached. Both unneces
sary as well as overutilization of the ACLF exists. While
ACLFs are generally perceived as a "last resort" option,
networks had low utilization of home support services prior
to ego's ACLF entry. This fact, coupled with the high
variability in ego's presenting health status, implies that
at least for some residents ACLF entry may have been unnec
essary or premature. Yet, for other residents ACLFs may
assume a short-term caring function when ego's network is
unwilling or unable to provide this service.


APPENDIX J
VARIABLE EFFECTS ON THE
PROCESS OF ACLF ENTRY


131
ego's mental health status. Thus, this picture is a bit
more complete. Although these findings are different, they
are not incompatible with the findings of prior research.
In conclusion, at the time of ACLF entry both morpho
logical and interactional network differences were present
between whites and nonwhites, males and females, private
payers and state-financed residents, and those who were of
relatively good health and those who were incompetent or had
at least one self-care deficit. Significant differences
were found in density and degree, network size, the number
of people materially linked to ego, network emotional bond
edness, perceived and objective measures of linkage direc
tionality, and the patterns and frequency of ego's contact
with network members. Interactional between-group differ
ences were shown for race, sex, socioeconomic status, and
health. Structural between-group differences were demon
strated for race, sex, and health only.


281
6. Which of the following best compares your current
physical care with that received at (insert name
of former
ACLF)?
(0)
The caregivers here
of technical care
give
me
a higher
level
(1)
The caregivers here
of technical care
give
me
the same
level
(2)
The caregivers here
of technical care
give
me
a lower
level
7.Which of the following best compares the emotional
atmosphere in your current residence with that
experienced at (insert name of former ACLF)?
(0)
The caregivers
about me
here
seems
to
care
more
(1)
The caregivers
about me
here
seem
to
care
the same
(2)
The caregivers
about me
here
seem
to
care
less
8. Could you please identify any problems that you or
your caregivers are currently experiencing? [Go on
to (12).]
9. How are things going for you now?
10. How would you describe the physical c