| | The impact of social support and sense of coherence on health-related quality of life among nursing home residents—A questionnaire survey in Bergen, NorwayReceived 3 January 2008; received in revised form 9 July 2008; accepted 10 July 2008. Abstract Background and objectivesFew studies have examined the association between social support and health-related quality of life (HRQOL) among nursing home residents and whether the sense of coherence (SOC) modifies the effect of social support on health-related quality of life. The main aims of this study were to determine the relationship between social support and HRQOL and to investigate whether the SOC modifies the effect of social support on HRQOL. DesignA cross-sectional, descriptive, correlational design. SettingsAll 30 nursing homes in Bergen in western Norway. ParticipantsTwo hundred and twenty-seven mentally intact long-term nursing home residents 65 years and older. MethodsData were obtained through face-to-face interviews using the SF-36 Health Survey, Social Provisions Scale and Sense of Coherence Scale. Possible relationships between the Social Provisions Scale and the eight SF-36 subdimensions were analysed using multiple linear regression while controlling for age, sex, marital status, education and comorbid illness. Interactions between the Sense of Coherence Scale and Social Provisions Scale were investigated. ConclusionsThe opportunity to provide nurturance for others appears to be important for social functioning, and sense of competence and sense of self-esteem appear to be important for vitality. Further, the residents’ relationships with significant others comprise an important component of mental health. Finally, independent of the level of sense of coherence, social support is an important resource for better health-related quality of life. Clinical nurses should recognize that social support is associated with health-related quality of life and pay attention to the importance of social support for the residents in daily practice. What is already known about the topic? •Social support is important for mental health for older people •Low levels of social support are associated with emotional problems •Sense of coherence has a moderating effect What this paper adds? •The opportunity to provide nurturance for others appears to be important for social functioning •A sense of competence and self-esteem appear to be important for vitality •These results suggest that, independent of the sense of coherence, social support is an important resource for better health-related quality of life 1. Introduction  Nursing home (NH) admissions are usually triggered by the inability to continue independent living in the community due to extensive impairment of basic activities of daily living, mainly multiple morbidity or dementia-related symptoms. Even intensive home nursing cannot adequately deal with this. Impairment due to dementia causes the vast majority of admissions to NHs in Norway (Nygaard et al., 2000). NH residents without dementia, who constitute a minority, albeit an important one, concomitantly often have somatic and/or other mental conditions, and coping with multiple morbidity can be stressful. In addition, the residents may also be exposed to other stressful events such as loss of home and relational losses. Any or all of these conditions may influence their health-related quality of life (HRQOL). The ultimate goal of NH care is to assist residents in encouraging functioning and HRQOL. It would therefore be of interest to determine whether social and personal resources influence HRQOL. This knowledge is important to NH staff in elaborating nursing regimens that may improve residents’ HRQOL. To review previous research on social support, sense of coherence and HRQOL among older people, we searched Medline (1996–2008), PsycINFO (1985–2008) and the Cinahl® Database (1987–2008) using the terms social contact, social network, social support, psychosocial support, interpersonal relation, nursing home, residential care, long-term care, health-related quality of life, well-being and quality of life. Several studies have showed that social support is an important resource for older people in maintaining their functioning (Sherbourne et al., 1992) and well being (Elovainio and Kivimake, 2000, Sherbourne et al., 1992, Wong et al., 2007). Further, social support is associated with physical health (Sherbourne et al., 1992, Travis et al., 2004), mental health (Liu and Guo, 2007, Routasalo et al., 2006) and HRQOL (Fortin et al., 2006, Garcia et al., 2005). The natural source of social support is a spouse, family and friends. A previous study of 13 NHs in Bergen (Drageset, 2004) showed that about 64% of the residents were widowed, and the frequency of contact with family (Bondevik and Skogstad, 1996) and friends (Bondevik and Skogstad, 1996, Drageset, 2002) was mainly monthly. Contact that provides a sense of security and intimacy and a sense of companionship contributes to well being (Farber et al., 1991, Lee et al., 2005). More frequent contact does not mean that the social integrity is better (Seeman et al., 1996), and the quality of social support is more strongly related to well being than is the quantity of social contact (Carpenter, 2002, Chi and Chou, 2001, Pinquart and Sorensen, 2000). People who lack social support are frequently vulnerable to depression (Prince et al., 1997, Tiikkainen and Heikkinen, 2005). The influence of social support on HRQOL among NH residents has received limited attention, although low levels of social support are significantly related to a variety of emotional problems (Bondevik and Skogstad, 1998, Lefrancois et al., 2000, Lin et al., 2007). 1.1. Theoretical framework and review of previous research Social support refers to the qualitative aspect described as perceived social support, such as the content and availability of relationships with significant others, and social network refers to the quantitative and structural aspects of relationships (Sarason et al., 1990). Weiss (1974) identified and described six categories of relational provisions, each associated with a particular type of relationship. Weiss’ provisions can be divided conceptually into two broad categories: non-assistance-related and assistance-related provisions (Cutrona and Russel, 1987). The non-assistance-related provisions include the following. (1) Attachment is provided by relationships from which the person gains a sense of safety and security. The absence of such relationships may result in the loneliness of emotional isolation. (2) A network of relationships in which the person shares concerns and common interests provides social integration. The absence of social integration may result in the loneliness of social isolation. (3) Opportunity for nurturance is being responsible for the care of others; absence may result in meaninglessness. (4) Reassurance of worth means a sense of competence and esteem. The absence of support for a sense of worth may lead to low self-regard. The assistance-related provisions include the following. (5) Reliable alliance is derived from relationships in which the person can count on assistance in times of need. The absence of reliable alliance may result in a sense of vulnerability. (6) Guidance is having relationships with people who can provide knowledge and advice. The absence of guidance may lead to feeling uncertainty and anxiety. Weiss’ framework appears appropriate for understanding the relationships between social interaction and mental well-being, as older people in NHs may experience changes in close relationships, relocation, failing health or the death of a spouse or friends (Mancini and Blieszner, 1992). Several studies have been based on Weiss’ concept of social support. Cutrona et al. (1986) found that reassurance of worth and opportunity for nurturance significantly predicted physical health for older people, and the provision of reliable alliance and guidance interacted with stress in predicting mental health. Mancini and Blieszner (1992) found that social provisions were important for people 65 years or older living in the community and were met by close relationships with significant others such as family and friends. Felton and Berry (1992) confirmed the importance of fulfilling social provisions among people 63–90 years old staying in the geriatric clinic of a large hospital and how this related with well being. Felton and Berry found that reassurance of worth was most valuable when the source was not family, but reliable alliance was related to family. In a 10-year follow-up study among men and women who were 80 years old in 1990, Lyyra and Heikkinen (2006) found that the risk of death was almost 2.5 times higher among women in the lowest tertile of non-assistance-related social support (comprising infrequent experiences of reassurance of worth, emotional closeness, sense of belonging and opportunity for nurturance) than among women in the highest tertile. In a 5-year follow-up study among people aged 80 years or older living in the community, Tiikkainen and Heikkinen (2005) found negative associations between depression and the subdimensions attachment, reassurance of worth, reliable alliance and guidance and between loneliness and the subdimensions social integration, attachment and reliable alliance. Social support has been shown to be important for emotional and social loneliness among NH residents (Bondevik and Skogstad, 1996, Bondevik and Skogstad, 1998, Drageset, 2004, Drageset, 2002) Thus, social support and its relationships with health and well being among older people seem to be important. Sense of coherence (SOC) may modify the effect of social support on HRQOL. Antonovsky, 1979, Antonovsky, 1987 examined health-promoting factors in his salutogenic model and developed the concept of SOC to explain why some people become ill when stressed whereas others remain healthy. SOC is defined as “global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence” (Antonovsky, 1987, p. 19). SOC is a general expression of an individual view of the world and includes comprehensibility, manageability and meaningfulness. High SOC suggests that an individual possesses resources that enable him or her to cope with various kinds of stressful life events. Antonovsky (1987) hypothesized that strong SOC would determine whether the outcome of stressful life events would be noxious, neutral or salutary: that is, SOC changes the relationship between strain and stress. SOC seems to have a moderating effect (Eriksson and Lindstrom, 2006), and studies of adults not living in NHs (Albertsen et al., 2001, Anson et al., 1993, Siglen et al., 2007) support SOC being such a moderator. Social support is another factor that can influence the effect of strain. It has also been hypothesized that SOC again might modify the effect of social support such that people lacking social support might still be able to cope with stress if they have a high SOC. In our context, one might therefore expect that, the higher the SOC, the lower the difference in perceived HRQOL between residents with high and low social support. A study of workers (Feldt, 1997) found such a relationship: good social relations at work heightened well being among subjects with very weak SOC. Since SOC and social support have also been shown to predict well being among older people (Elovainio and Kivimake 2000), we wanted to investigate whether SOC has any moderating effect on HRQOL among NH residents. To our knowledge, the likelihood of any moderating role of SOC on HRQOL among NHs residents has not been studied extensively. 1.2. Aims The main aims were to determine the relationship between social support and HRQOL and to investigate whether SOC modifies the effect of social support on HRQOL. 2. Methods 2.1. Design and setting A cross-sectional, descriptive, correlation design was used. All long-term care residents (n =2042) from the 30 NHs in the city of Bergen, Norway were potential participants. The study was carried out between 15 January 2004 and 31 May 2005. All participants included provided informed consent. The Western Norway Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the study. 2.2. Subjects All cognitively intact NH residents aged 65 years and older who were capable of carrying out a conversation and had been residing in the NH for at least 6 months were eligible for the study. Cognitively intact was defined as having a Clinical Dementia Rating (CDR) ≤0.5 (Hughes et al., 1982). CDR was created as a staging instrument for dementia and described as no impairment (0), very mild (0.5), mild (1), moderate (2) and severe (3) dementia, and the overall level of impairment is derived by standard algorithm. We did not carry out a dementia work-up but used the CDR (Engedal and Haugen, 1993, Hughes et al., 1982, Nygaard and Ruths, 2003) to rate cognitive functioning. Two studies in Norway (Engedal and Haugen, 1993, Nygaard and Ruths, 2003) have shown that CDR staging is a valid substitute for a dementia work-up among NH residents. Trained nurses who knew the residents well assessed CDR, and the nurses were instructed to base their scoring on CDR items solely on mental functioning not including physical frailty. One study in Australia (Waite et al., 1999) has shown that CDR based solely on informant data is valid among community residents. We also kept strictly to the scoring algorithm of the CDR, which gives extra weight to memory function (Morris, 1993). CDR has shown high interrater reliability (Marin et al., 2001, McCulla et al., 1989). Of 2042 NH residents, 252 fulfilled the inclusion criteria and were invited by a primary care nurse to participate. Of these, 25 (10%) declined to participate. The NH sample comprised 227 residents for data collection and analysis. The study's power was assessed post hoc. With 250 subjects, the power was at least 90% in a two-sided hypothesis test at the 5% level to detect a correlation of at least 0.20. With 230 subjects, the power was at least 90% in a two-sided hypothesis test at the 5% level to detect a correlation of at least 0.21. The data were obtained through face-to-face interviews. The interview took place in the respondent's room or at another appropriate location in the nursing home. The principal investigator (JD) recorded the demographic information and performed the interviews: that is, reading the questions to the participants and circling the indicated answer. This was necessary, as many of the residents have problems holding a pen and have reduced vision. Each participant received a large-type version of the questionnaire so they could follow the questions. The principal investigator ensured that the questions were understood. Thus, the NH sample comprised 227 residents for data collection and analysis. 2.3. Instruments Sociodemographic data such as age, sex, marital status and educational level were collected. All comorbid illnesses were assessed from the medical records. Diagnoses were classified using the Functional Comorbidity Index, a clinically based measure developed by Groll et al. (2005). The Functional Comorbidity Index includes 18 diagnoses scored present (=1) and not present (=0) and has a maximum score of 18. Social support was assessed using the revised Social Provisions Scale (Cutrona and Russel, 1987). The scale contains 24 items, four for each of the six social provisions “attachment”, “social integration”, “nurturance”, “reassurance of worth”, “reliable alliance” and “guidance” according to Weiss (1974). Since “reliable alliance” and “guidance” are highly correlated with the other subscales (Mancini and Blieszner, 1992, Russel et al., 1984), “reliable alliance” and “guidance” were omitted in accordance with Andersson and Stevens (1993). The responses were scored using “strongly disagree”, “disagree”, “agree” and “strongly agree”. High scores indicate high social provision. The instrument with four subdimensions “attachment”, “social integration”, “nurturance” and “reassurance of worth” has been used in studies of older people living in the community (Andersson and Stevens, 1993, Bondevik and Skogstad, 1996) and among NH residents (Bondevik and Skogstad, 1996, Bondevik and Skogstad, 1998, Drageset, 2004, Drageset, 2002). The NH studies have shown high reliability (Cronbach's alpha; attachment 0.83–0.85, social integration 0.86–0.92, reassurance of worth 0.92–0.93 and nurturance 0.85–0.92) and validity (a confirmatory factor analysis (eigenvalue >1, varimax rotation) confirms the four predefined dimensions of social provisions). The Sense of Coherence Scale (SOC-13) was used to estimate the residents’ SOC. The scale has a 7-point Likert-scale format with two anchor responses, “never” and “very often”. The items measured were perceived comprehensibility (5 items), manageability (4 items) and meaningfulness (4 items). The score ranges from 13 to 91; high score indicates strong SOC. A systematic review of the validity and reliability of the SOC-13 scale (Eriksson and Lindstrom, 2005) showed that it is generally acceptable among older people. Studies of SOC have not provided any convincing results on stability over time, and the evidence for the validity of the scale is limited, especially construct validity (Eriksson and Lindstrom, 2005). Missing data were substituted separately for everyone who answered at least half the questions for each component. Only 7 of 227 (3.1%) had one or more items unanswered. At the individual level, the percentage of missing values ranged from 0% (6 items) to 2.2% (item 11). This gave missing substitution for 3.1% of the total SOC scales and 2.2% for comprehensibility, 0.9% for manageability and 1.3% for meaningfulness. HRQOL was measured using the SF-36 Health Survey (Ware and Sherbourne, 1992). The SF-36 comprises 36 questions (items) along eight dimensions: physical functioning (10 items), general health (5 items), mental health (5 items), bodily pain (2 items), role limitation related to physical problems (4 items), role limitation related to emotional problems (3 items), social functioning (2 items) and vitality (4 items). An additional item, reported health transition, notes changes in general health over the past year. The response scores for each dimension are added, and the total is converted to a score between 0 and 100 (highest) (Ware and Sherbourne, 1992, Ware et al., 1994). A higher score indicates higher HRQOL. The SF-36 has been used in numerous studies with older people and has demonstrated high reliability (Cronbach's alpha: 0.72–0.94) (Lyons et al., 1994, Pit et al., 1996) and good construct validity (Lyons et al., 1994) and convergent validity (Andresen et al., 1999). Using SF-36 in measuring HRQOL among older NH residents gives the opportunity to compare the results with the general older population and with other relevant studies abroad. Missing substitution was performed to calculate the score for dimensions when less than 50% of the questions were unanswered (Ware, 2005): physical functioning (3.1%), role limitation–physical score (2.6%) and role limitation–emotional (1.8%). At the individual level, the percentage of missing values for the items in the SF-36 question ranged from 0% (12 items) to 2.6% (item 3). 2.4. Data analysis Descriptive statistics for the demographic variables, the comorbidity variable, SF-36 subdimensions, social support subscales and SOC-13 were calculated. The reliability of each of the SF-36 subdimensions, SOC-13 and Social Provisions Scale was assessed using Cronbach's alpha. The possible effects of the social support subscales and the SOC-13 on the SF-36 subdimensions while controlling for age, sex, marital status, education and comorbidity were analysed by using multiple regression in the general linear model procedure of SPSS for Windows. Sex, age group, marital status and education were coded as categorical variables and the social support subscales, SOC and comorbidity as continuous covariates. The effects of SOC on the SF-36 subdimensions were initially assessed by calculating the mean score of the SF-36 subdimensions in 4 groups according to the quartiles of the distributions of SOC. The relationship across these 4 groups was approximately linear for all SF-36 subdimensions, and the SOC was therefore used as a continuous variable in the regression analysis. To investigate whether SOC modified the relationship between the social support variables and the SF-36 subdimensions, the interaction effects between SOC and social support subscales on the SF-36 scales were tested in general linear models as described above. SPSS for Windows (Version 14.0, 2005) was used (Morgan and Griego, 1998) for all statistical analysis. A significance level of 0.05 was applied throughout. 3. Results Table 1 presents the demographic characteristics and comorbidity (Functional Comorbidity Index) of the 227 respondents. The mean age was 85.4 years (range 65–102), and the average stay at the time of the interview was 24 months (range 6–119). The residents had 0–6 comorbid illnesses (median 2, mean 1.9, standard deviation 1.2). The most common diagnoses were stroke or transitory ischaemic attack: 67 (29.5%); depression: 40 (17.6%); congestive heart failure (or heart disease): 38 (16.7%); and diabetes types 1 and 2: 38 (16.7%). | | |  | | Women | Men | Total | |
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| | n | % | n | % | n | % | |
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| Sex | 164 | 72.2 | 63 | 27.8 | 227 | 100.0 | | | Age (years) | | | 65–74 | 12 | 7.3 | 8 | 12.7 | 20 | 8.8 | | | 75–84 | 48 | 29.3 | 30 | 47.6 | 78 | 34.4 | | | 85–94 | 80 | 48.8 | 24 | 38.1 | 104 | 45.8 | | | ≥95 | 24 | 14.6 | 1 | 1.6 | 25 | 11.0 | | | | | | Marital status | | | Widowed | 118 | 72.0 | 26 | 41.3 | 144 | 63.4 | | | Married or cohabiting | 13 | 7.9 | 25 | 39.7 | 38 | 16.7 | | | Unmarried | 27 | 16.5 | 8 | 12.7 | 35 | 15.4 | | | Divorced | 6 | 3.7 | 4 | 6.3 | 10 | 4.4 | | | | | | Education | | | Primary school only | 76 | 46.3 | 21 | 33.3 | 97 | 42.7 | | | <3 years after primary school | 70 | 42.7 | 32 | 50.8 | 102 | 44.9 | | | ≥3 years after primary school | 18 | 11.0 | 10 | 15.9 | 28 | 12.3 | | | | | | Illnesses | | | Yes (FCI†≥1) | 146 | 89.0 | 52 | 82.5 | 198 | 87.2 | | | No (FCI†=0) | 18 | 11.0 | 11 | 17.5 | 29 | 12.8 | | | | |
Among the SF-36 subscales, residents scored highest on bodily pain (less pain), social functioning and role-emotional functioning (less limitation in social functioning and role-emotional) and lowest on physical functioning (more limitation in physical functioning). Among social support subscales, attachment had the highest score and nurturance the lowest. Men had higher SOC-13 scores than women (Table 2); the minimum was 25 and maximum 90. Cronbach's alpha for the SF-36 subscales ranged from 0.91 to 0.72, with highest values on physical functioning and the lowest on social functioning. For social support subscales, the values of Cronbach's alpha were: attachment 0.85, social integration 0.87, reassurance of worth 0.84 and nurturance 0.79. For SOC, Cronbach's alpha was 0.86. | | | | | Women | Men | Total | |
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| | Mean | S.D.† | Mean | S.D.† | Mean | S.D.† | |
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| SF-36 subscales | | | Physical function | 16.2 | 21.2 | 19.6 | 21.9 | 17.2 | 20.5 | | | Role limitations, physical | 56.6 | 43.4 | 65.2 | 40.4 | 58.9 | 42.7 | | | Bodily pain | 68.1 | 33.3 | 79.0 | 29.9 | 71.1 | 32.7 | | | General health perceptions | 56.0 | 21.1 | 53.0 | 21.0 | 55.2 | 21.1 | | | Vitality | 42.0 | 21.3 | 41.1 | 20.4 | 41.8 | 21.0 | | | Social functioning | 74.6 | 27.9 | 68.4 | 30.3 | 72.9 | 28.6 | | | Role limitations, emotional | 73.3 | 38.5 | 67.4 | 40.5 | 71.7 | 39.1 | | | Mental health | 70.0 | 20.2 | 67.8 | 21.3 | 69.4 | 20.5 | | | | | | Social Provisions Scale | | | Attachment | 13.7 | 3.0 | 12.3 | 3.6 | 13.3 | 3.2 | | | Social integration | 11.4 | 3.4 | 11.3 | 3.4 | 11.3 | 3.4 | | | Nurturance | 6.0 | 3.3 | 6.7 | 3.8 | 6.2 | 2.9 | | | Reassurance of worth | 12.4 | 2.9 | 13.1 | 2.9 | 12.9 | 2.9 | | | Sense of Coherence Scale (SOC-13) | 67.7 | 14.7 | 69.6 | 11.8 | 69.1 | 12.7 | | | | |
After adjustment for age group, sex, marital status, educational level and comorbidity, attachment significantly affected the mental health subscale, opportunity for nurturance significantly affected the social functioning subscale and reassurance of worth significantly affected vitality (Table 3). | | | | Subscales | Physical functioning (β 95% CI) | Role limitations, physical (β 95% CI) | Bodily pain (β 95% CI) | General health (β 95% CI) | Vitality (β 95% CI) | Social functioning (β 95% CI) | Role limitations, emotional (β 95% CI) | Mental health (β 95% CI) | |
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| Model 1§ | | | Social Provisions Scale | | | Attachment | 0.2 (−0.9, 1.3) | 1.1 (−1.2, 3.3) | −0.5 (−2.2,1.2) | 0.4 (−0.7, 1.6) | 0.7 (−0.3,1.8) | 0.9 (−0.6, 2.3) | 1.3 (−0.8, 3.3) | 1.8 (0.7, 2.8) | | | Social integration | −0.3 (−1.3, 0.7) | −2.0 (−4.1, 0.1) | −0.3 (−1.9, 1.3) | −0.1 (−1.1, 1.0) | 0.0 (−0.9,1.0) | −0.8 (−2.2, 0.6) | −0.1 (−2.0, 1.9) | −0.6 (−1.6, 0.4) | | | Nurturance | 0.6 (−0.4, 1.6) | −0.6 (−1,5, 2.8) | −0.9 (−2.5, 0.7) | 0.3 (−0.7, 1.3) | 0.6 (−0.4, 1.6) | 2.1 (0.8, 3.5) | −0.8 (−2.7, 1.1) | 0.2 (− 0.7, 1.2) | | | Reassurance of worth | 0.8 (−0.4, 1.9) | 0.8 (−1.6, 3.2) | 0.6 (−1.2, 2.3) | 0.9 (−0.3, 2.1) | 2.0 (0.8, 3.1) | 0.8 (− 0.8, 2.4) | 1.5 (−0.7, 3.7) | 0.7 (−0.4, 1.8) | | | | | | Model 2§ | | | Social Provisions Scale | | | Attachment | −0.3 (−1.4, 0.7) | − 0.3 (−2.4, 1.8) | −1.5 (−3.1, 0.1) | −0.3 (−1.4, 0.7) | 0.1 (−0.9, 1.2) | 0.1 (−1.4, 1.5) | 0.1 (−1.9, 2.0) | 0.8 (−0.1, 1.7) | | | Social integration | −0.3 (−1.2, 0.7) | −1.9 (−3.8, 0.1) | −0.2 (−1.7, 1.2) | 0.0 (−1.0, 0.9) | 0.1 (− 0.8, 1.0) | − 0.7 (−2.0, 0.6) | 0.0 (−1.8, 1.8) | −0.5 (−1.3, 0.3) | | | Nurturance | 0.4 (−0.5, 1.4) | 0.3 (−1.7, 2.2) | −1.2 (−2.6, 0.3) | 0.1 (−0.9, 1.0) | 0.4 (−0.5, 1.4) | 1.9 (0.6, 3.2) | −1.1 (−2.9, 0.7) | −0.0 (−0.8, 0.8) | | | Reassurance of worth | 0.2 (−1.0, 1.3) | −0.8 (−3.1, 1.5) | −0.6 (−2.3, 1.1) | 0.0 (−1.1, 1.1) | 1.3 (0.2, 2.4) | −0.2 (−1.7, 1.3) | 0.1 (−2.0, 2.2) | −0.5 (−1.4, 0.5) | | | SOC-13† | 0.5 (0.3, 0.8) | 1.4 (1.0, 1.9) | 1.0 (0.6, 1.3) | 0.8 (0.6, 1.0) | 0.6 (0.4, 0.8) | 0.8 (0.5, 1.1) | 1.3 (0.8, 1.7) | 1.0 (0.8, 1.2) | | | | |
Including SOC in the analysis reduced the effect of nurturance on social functioning, but this was still significant (Table 3). Similarly, the effect of reassurance of worth on vitality was also reduced but still significant. However, the relationship between attachment and mental health disappeared. No interaction was found (p=0.34–0.69), and SOC-13 score significantly affected all SF-36 subscales (Table 3). 4. Discussion This study among cognitively intact NH residents found that higher levels of attachment, nurturance and reassurance of worth were associated with higher levels of mental health, social functioning and vitality, respectively, and that lower scores on these social support subdimensions were correlated with lower HRQOL. These findings might suggest that attachment positively affects mental health, opportunity for nurturance improves social functioning and reassurance of worth promotes vitality. However, because of the cross-sectional study design, we cannot firmly conclude on the direction of a possible causal effect or preclude that other unmeasured determinants cause these associations. Nevertheless, the positive relationship between attachment and mental health suggests that the emotional content of the relationship with significant others is an important component of mental health. Our findings correspond with other studies (Felton and Berry, 1992, Lyyra and Heikkinen, 2006, Tiikkainen and Heikkinen, 2005). According to Weiss, 1973, Weiss, 1974 and Mullins and Dugan (1991), significant others are spouses and very close friends who provide the feeling of intimacy, security and peace. In the current study, 63% of the residents were widowers or widows, and their advanced age means that many have lost many people close to them from their generation. Regarding attachment, other significant relationships may therefore play a compensatory role. Weiss (1987) also emphasizes that an attachment figure is not necessarily a person with whom you are intimate but rather a figure that provides security because of emotional and perceptional linkage. NH residents are always surrounded by other people and may therefore have the opportunity to establish new relationships (Carpenter, 2002, Fessmann and Lester, 2000, Lin et al., 2007). In addition, in our context the nursing care personnel can also provide security (Weiss, 1987), as shown in some studies (Carpenter, 2002, Lin et al., 2007, Tseng and Wang, 2001). The positive relationship between opportunity for nurturance and social functioning suggests that providing support for others is important for social functioning. Weiss (1974) claimed that nurturance differs from the other provisions by enquiring whether older people themselves provide support. Andersson and Stevens (1993) chose to eliminate nurturance because of the complexity of the topic among older people. In contrast, other studies (Aldwin, 1990, Cutrona et al., 1986, Mullins and Dugan, 1991) considered nurturance to be important for older people. Thus, although the role of nurturance changes as people grow older, some of the residents may define themselves as still being in an assistance-giving role and still feel responsibility for the well being of significant others, such as children, other family members and friends. Our findings show that reassurance of worth is positively related to vitality, suggesting that a sense of competence and self-esteem are important for vitality. This could mean that the more a person's skills and abilities are acknowledged, the better the person's vigour and energy will be. The feeling of being needed and valued is essential to strengthening self-esteem (Weiss, 1974) and to preventing depression (Tiikkainen and Heikkinen, 2005). Reassurance of worth is also critical for the survival of older women (Lyyra and Heikkinen, 2006). According to Weiss (1974) and Felton and Berry (1992), reassurance of worth views a person as competent in a social role and is usually provided by non-kin. The non-familial relationships for the residents are other residents and friends outside the NH. Since most NH residents have dementia (Nygaard, 2002), interaction with other residents without cognitive impairment is limited. Co-determination in relation to daily life is an aspect of verifying one's self-esteem (Franklin et al., 2006, Murphy et al., 2007). Again, one cannot exclude the possibility that this association could be related to a reversed effect: that is, that individuals experiencing good vitality for other reasons would perceive better reassurance of worth. This seems less probable considering the results from previous studies (Lyyra and Heikkinen, 2006, Tiikkainen and Heikkinen, 2005). When SOC was included in the analysis, the positive relationship between nurturance and social functioning was reduced but still significant, as was the positive relationship between reassurance of worth and vitality, but the positive relationship between attachment and mental health was no longer significant. This means that SOC partly explains the positive relationship between nurturance and social functioning and between reassurance of worth and vitality. Thus, when the effect of SOC is controlled for, nurturance still seems to contribute to better social functioning, and reassurance of worth continues to contribute to better vitality. SOC was significantly related to the SF-36 subdimensions and was especially highly correlated with mental health (r=0.62). In this situation, controlling for SOC, the estimated effect of attachment on mental health might be considered an overadjustment. This result shows that social support might be an important resource for the residents in this study. However, a high level of HRQOL may also enable the residents to become part of a social network and receive social support. Further, the findings can be related to the research on person-centred care in dementia care (Kitwood, 1997). Person-centred care constitutes the key elements of comfort, attachment, inclusion, occupation, identity and love. These are emphasized as being essential to enable a good life in NHs. These elements are, however, basic to any person, and in this setting (NH residents without cognitive impairment), social support can be considered as part of person-centred care. No significant moderating effects were found: that is, no significant interaction terms. These results do not support the moderating effect of SOC. This could suggest that social support benefits HRQOL independent of the SOC. This means that the effect of SOC on HRQOL does not vary with the level of social support or, similarly, the effect of social support on HRQOL does not vary according to SOC. In a clinical setting, this means that social support is important for the residents’ HRQOL independent of their level of sense of coherence, and SOC is important to HRQOL for the residents independent of their social support. Finding significant interaction effects in a multivariate model requires substantial statistical power provided by strong effects and large sample sizes. This study might not have had such power. Of the 252 subjects, 25 refused to participate. This was very few given the specific frail population. However, nurses who knew the eligible subjects well asked them to participate. Eligible participants were selected from all NHs in Bergen. The results should therefore generally be applicable to subjects living in NHs in Bergen who fulfilled the inclusion criteria. Some studies (Andresen et al., 1999, Hayes et al., 1995, Murray et al., 1998) have suggested that face validity appears to be a limitation for using some of the questions of the SF-36 (physical functioning and role–physical) among older people and those living in long-term care. In our study, the data were obtained from personal interviews, and respondents said they clearly understood the questions, increasing the validity of the findings. In addition, few data were missing on the physical functioning and role–physical subscales, suggesting that NH residents were comfortable with these questions. Very few data were missing for SOC-13 in this study, and the respondents did not find the questions difficult to answer. The face validity of the SOC-13 seems to be acceptable. As the study had a cross-sectional design, we cannot draw any causal conclusions or strong practical implications from it but only interpret the results as an association. Thus, the relationship between social support and HRQOL may be bidirectional. However, further research is needed on the directions of variables. 5. Clinical implications and conclusion The study indicates that the relationships between NH residents and significant others appear to be an important component of mental health, and the opportunity to provide nurturance for others appears to influence social functioning. Ensuring that nurses arrange for and encourage the residents’ contact with significant others therefore seems to be crucial. However, nurses should be sensitive to residents’ own priorities. Further, nursing care must assist residents in increasing the awareness of opportunities for nurturing. Older people can continue to provide nurturing for other people. Our findings show that a sense of competence and self-esteem appear to be important for vitality. Nursing staff should therefore pay attention to the importance to verifying the residents’ self-esteem in daily practice. This can be done by giving residents the opportunity to influence choices and utilize their own resources in the activities of daily living and daily routine and by respecting the residents’ attitudes and values in decision-making. Both self-respect and other people's respect for one's own personal values have been shown to be important for self-esteem and quality of life (Bergland and Narum, 2007). Organizational barriers such as few nursing staff, lack of funding and lack of competence have been shown to influence the quality of care in NHs, which in turn affects the quality of life (Kirkevold and Engedal, 2006, Yeh et al., 2003), well being and thriving in NHs (Bergland and Kirkevold, 2006). Meeting the older residents’ physical and psychosocial needs requires having appropriately qualified staff members who have the time and expertise to provide high-quality services to this group of people. Further, assisting residents in gaining some sense of control over their daily lives is also important. Finally, our results show that, independent of the SOC, social support is a vital resource for better HRQOL. Longitudinal research is needed to examine this relationship more closely. This study had no data on who gives the social support, as described by Weiss (1974), and the quality of such support, and further research is therefore needed. Further, a much larger sample size is needed to show whether SOC exerts its influence by modifying social support in relation to HRQOL. Conflict of interest The authors declare that they have no competing interests. Funding: Grants from the Norwegian Health Association and Bergen University College supported this research. Etical approval statement: Mention in 2.1 Design and setting, The Western Norway Regional Commitee for Medical Research Ethics and Norwegian Social Sience Data Services approved the study (REK. Vest nr. 162.03) References Albertsen et al., 2001. 1.Albertsen K, Nielsen M, Borg V. The Danish psychosocial work environment and symptoms of stress: the main, mediating and moderating role of sense of coherence. Work & Stress. 2001;15(3):241–253. Aldwin, 1990. 2.Aldwin CM. The elders life stress inventory: egocentric and nonegocentric stress. In: Paris-Stephens MA, Crowther JH, Hobfoll SE, Tennebaum DL editor. Stress and Coping in Late-life Families. New York: Hemisphere Publishing Corporation; 1990;p. 49–76. Andersson and Stevens, 1993. 3.Andersson L, Stevens N. Associations between early experiences with parents and well-being in old age. Journal of Gerontology. 1993;48(3):109–116. Andresen et al., 1999. 4.Andresen EM, Gravitt GW, Aydelotte ME, Podgorski CA. Limitations of the SF-36 in a sample of nursing home residents. Age Ageing. 1999;28(6):562–566. MEDLINE |
CrossRef
Anson et al., 1993. 5.Anson O, Carmel S, Levenson A, Bonneh DY, Maoz B. Coping with recent life events: the interplay of personal and collective resources. Behavioral Medicine. 1993;18(4):159–166. MEDLINE Antonovsky, 1979. 6.Antonovsky A. Health, Stress and Coping: New Perspectives on Mental and Physical Well-being. San Francisco: Jossey-Bass; 1979;. Antonovsky, 1987. 7.Antonovsky A. Unraveling the Mystery of Health: How People Manage Stress and Stay Well. San Francisco: Jossey-Bass; 1987;. Bergland and Kirkevold, 2006. 8.Bergland A, Kirkevold M. Thriving in nursing homes in Norway: contributing aspects described by residents. International Journal of Nursing Studies. 2006;43(6):681–691. Abstract | Full Text |
Full-Text PDF (259 KB)
|
CrossRef
Bergland and Narum, 2007. 9.Bergland A, Narum I. Quality of life demands comprehension and further exploration. Journal of Aging and Health. 2007;19(1):39–61. MEDLINE |
CrossRef
Bondevik and Skogstad, 1996. 10.Bondevik M, Skogstad A. Loneliness among the oldest old, a comparison between residents living in nursing homes and residents living in the community. International Journal of Aging and Human Development. 1996;43(3):181–197. MEDLINE Bondevik and Skogstad, 1998. 11.Bondevik M, Skogstad A. The oldest old, ADL, social network, and loneliness. Western Journal of Nursing Research. 1998;20(3):325–343. MEDLINE |
CrossRef
Carpenter, 2002. 12.Carpenter BD. Family, peer and staff social support in nursing home patients: conbrutions to psychological well-being. Journal of Applied Gerontology. 2002;21:275–293.
CrossRef
Chi and Chou, 2001. 13.Chi I, Chou KL. Social support and depression among elderly Chinese people in Hong Kong. International Journal of Aging and Human Development. 2001;52(3):231–252. MEDLINE |
CrossRef
Cutrona and Russel, 1987. 14.Cutrona CE, Russel DW. The provisions of social relationships and adaptation to stress. In: Jones WH, Perlman D editor. Advances in Personal Relationships. A Research Annual I. Greenwich, CT: Jai Press Inc.; 1987;p. 37–67. Cutrona et al., 1986. 15.Cutrona C, Russell D, Rose J. Social support and adaptation to stress by the elderly. Psychology and Aging. 1986;1(1):47–54. MEDLINE |
CrossRef
Drageset, 2002. 16.Drageset J. Loneliness at nursing homes—does a network have any importance for loneliness among nursing home occupants?. Vard I Norden Nursing Science and Research in the Nordic Countries. 2002;22(2):9–14. Drageset, 2004. 17.Drageset J. The importance of activities of daily living and social contact for loneliness: a survey among residents in nursing homes. Scandinavian Journal of Caring Sciences. 2004;18(1):65–71. MEDLINE |
CrossRef
Elovainio and Kivimake, 2000. 18.Elovainio M, Kivimake M. Sense of coherence and social support—resources for subjective well-being and health of the aged in Finland. International Journal of Social Welfare. 2000;9:128–135. Engedal and Haugen, 1993. 19.Engedal K, Haugen PK. The prevalence of dementia in a sample of elderly Norwegians. International Journal of Geriatric Psychiatry. 1993;8:565–570.
CrossRef
Eriksson and Lindstrom, 2005. 20.Eriksson BL, Lindstrom B. Validity of Antonovsky's sense of coherence scale: a systematic review. Journal Epidemiology and Community Health. 2005;59:460–466. Eriksson and Lindstrom, 2006. 21.Eriksson M, Lindstrom B. Antonovsky's sense of coherence scale and the relation with health: a systematic review. Journal of Epidemiology and Community Health. 2006;60(5):376–381.
CrossRef
Farber et al., 1991. 22.Farber HJ, Brod M, Feinbloom RI. Primary family contacts and emotional health in the institutionalized elderly. Family Practice Research Journal. 1991;11(3):309–317. MEDLINE Feldt, 1997. 23.Feldt T. The role of sense of coherence in well-being at work: analysis of main and moderator effects. Work & Stress. 1997;11(2):134–147. Felton and Berry, 1992. 24.Felton BJ, Berry CA. Do the sources of the urban elderly's social support determine its psychological consequences?. Psychology and Aging. 1992;7(1):89–97. MEDLINE |
CrossRef
Fessmann and Lester, 2000. 25.Fessmann N, Lester D. Loneliness and depression among elderly nursing home patients. International Journal of Aging and Human Development. 2000;51(2):137–141. MEDLINE |
CrossRef
Fortin et al., 2006. 26.Fortin M, Bravo G, Hudon C, Lapointe L, Almirall J, Dubois MF, et al. Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research. 2006;15(1):83–91. MEDLINE |
CrossRef
Franklin et al., 2006. 27.Franklin LL, Ternestedt BM, Nordenfelt L. Views on dignity of elderly nursing home residents. Nursing Ethics: an International Journal for Health Care Professionals. 2006;13(2):130–146. Garcia et al., 2005. 28.Garcia EL, Banegas JR, Perez-Regadera AG, Cabrera RH, Rodriguez-Artalejo F. Social network and health-related quality of life in older adults: a population-based study in Spain. Quality of Life Research. 2005;14(2):511–520. MEDLINE |
CrossRef
Groll et al., 2005. 29.Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. Journal of Clinical Epidemiology. 2005;58(6):595–602. Abstract | Full Text |
Full-Text PDF (196 KB)
|
CrossRef
Hayes et al., 1995. 30.Hayes V, Morris J, Wolfe C, Morgan M. The SF-36 Health Survey questionnaire: is it suitable for use with older adults?. Age and Ageing. 1995;4:120–125. Hughes et al., 1982. 31.Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. British Journal of Psychiatry. 1982;140:566–572. MEDLINE |
CrossRef
Kirkevold and Engedal, 2006. 32.Kirkevold O, Engedal K. The quality of care in Norwegian nursing homes. Scandinavian Journal of Caring Sciences. 2006;20(2):177–183. MEDLINE |
CrossRef
Kitwood, 1997. 33.Kitwood T. The experiences of dementia. Aging & Mental Health. 1997;1:13–22.
CrossRef
Lee et al., 2005. 34.Lee LY, Lee DT, Woo J. Predictors of satisfaction among cognitively intact nursing home residents in Hong Kong. Research in Nursing and Health. 2005;28(5):376–387. MEDLINE |
CrossRef
Lefrancois et al., 2000. 35.Lefrancois R, Leclerc G, Hamel S, Gaulin P. Stressful life events and psychological distress of the very old: does social support have a moderating effect?. Archives of Gerontology and Geriatrics. 2000;31(3):243–255. Lin et al., 2007. 36.Lin PC, Wang HH, Huang HT. Depressive symptoms among older residents at nursing homes in Taiwan. Journal of Clinical Nursing. 2007;16(9):1719–1725.
CrossRef
Liu and Guo, 2007. 37.Liu LJ, Guo Q. Loneliness and health-related quality of life for the empty nest elderly in the rural area of a mountainous county in China. Quality of Life Research. 2007;16(8):1275–1280.
CrossRef
Lyons et al., 1994. 38.Lyons RA, Perry HM, Beverley N, Littlepage C. Evidence for the validity of the Short-form 36 Questionnaire (SF-36) in an elderly population. Age and Ageing. 1994;23(3):182–184. MEDLINE Lyyra and Heikkinen, 2006. 39.Lyyra TM, Heikkinen RL. Perceived social support and mortality in older people. Journal of Gerontology Part B: Psychological Sciences and Social Sciences. 2006;61(3):S147–S152. Mancini and Blieszner, 1992. 40.Mancini JA, Blieszner R. Social provisions in adulthood: concept and measurement in close relationships. Journal of Gerontology. 1992;47:14–20. Marin et al., 2001. 41.Marin DB, Flynn S, Mare M, Lantz M, Hsu MA, Laurans M, et al. Reliability and validity of a chronic care facility adaptation of the Clinical Dementia Rating scale. International Journal of Geriatric Psychiatry. 2001;16(8):745–750. MEDLINE |
CrossRef
McCulla et al., 1989. 42.McCulla MM, Coats M, Van Fleet N, Duchek J, Grant E, Morris JC. Reliability of clinical nurse specialists in the staging of dementia. Archives of Neurology. 1989;46(11):1210–1211. MEDLINE Morgan and Griego, 1998. 43.Morgan GA, Griego OV. Easy Use and Interpretation of SPSS for Windows: Answering Research Questions with Statistics.. Mahwah, NJ: Lawrence Erlbaum Associates; 1998;. Morris, 1993. 44.Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology. 1993;43(11):2412–2414. MEDLINE Mullins and Dugan, 1991. 45.Mullins LC, Dugan E. Elderly social relationships with adult children and close friends and depression. Journal of Social Behavior & Personality. 1991;6(2):315–328. Murphy et al., 2007. 46.Murphy K, Shea EO, Cooney A. Quality of life for older people living in long-stay settings in Ireland. Journal of Clinical Nursing. 2007;16(11):2167–2177.
CrossRef
Murray et al., 1998. 47.Murray M, Lefort S, Ribeiro V. The SF-36: reliable and valid for the institutionalized elderly?. Aging and Mental Health. 1998;2(1):24–27.
CrossRef
Nygaard, 2002. 48.Nygaard HA. Nursing home as a medical institution—a fata morgana?. Tidsskrift for Den Norske Legeforening. 2002;122(8):823–825. Nygaard and Ruths, 2003. 49.Nygaard HA, Ruths S. Missing the diagnosis: senile dementia in patients admitted to nursing homes. Scandinavian Journal of Primary Health Care. 2003;21(3):148–152. Nygaard et al., 2000. 50.Nygaard HA, Naik M, Ruths S. Mental impairment in nursing home residents. Tidsskrift for Den Norske Legeforening. 2000;120(26):3113–3116. Pinquart and Sorensen, 2000. 51.Pinquart M, Sorensen S. Influences of socioeconomic status, social network, and competence on subjective well-being in later life: a meta-analysis. Psychology and Aging. 2000;15(2):187–224. MEDLINE |
CrossRef
Pit et al., 1996. 52.Pit SW, Schurink J, Nair BR, Byles J, Heller RF. Use of the Short-Form-36 Health Survey to assess quality of life among Australian elderly. Australian Journal of Ageing. 1996;15(3):132–135. Prince et al., 1997. 53.Prince MJ, Harwood RH, Blizard RA, Thomas A, Mann AH. Social support deficits, loneliness and life events as risk factors for depression in old age The Gospel Oak Project VI. Psychological Medicine. 1997;27(2):323–332. MEDLINE |
CrossRef
Routasalo et al., 2006. 54.Routasalo PE, Savikko N, Tilvis RS, Strandberg TE, Pitkala KH. Social contacts and their relationship to loneliness among aged people—a population-based study. Gerontology. 2006;52(3):181–187.
CrossRef
Russel et al., 1984. 55.Russel D, Cutrona CE, Rose J, Yurko K. Social and emotional loneliness: an examination of Weiss's typology of loneliness. Journal of Personality and Social Psychology. 1984;46(6):1313–1321. MEDLINE |
CrossRef
Sarason et al., 1990. 56.Sarason BR, Sarason IG, Pierce GR. Social Support: An Interactional View. New York: Wiley; 1990;. Seeman et al., 1996. 57.Seeman TE, Bruce ML, McAvay GJ. Social network characteristics and onset of ADL disability: MacArthur studies of successful aging. Journal of Gerontology Part B: Psychological Sciences and Social Sciences. 1996;51(4):S191–S200. Sherbourne et al., 1992. 58.Sherbourne CD, Meredith LS, Rogers W, Ware JE. Social support and stressful life events: age differences in their effects on health-related quality of life among the chronically ill. Quality of Life Research. 1992;1(4):235–246. MEDLINE |
CrossRef
Siglen et al., 2007. 59.Siglen E, Bjorvatn C, Engebretsen LF, Berglund G, Natvig GK. The influence of cancer-related distress and sense of coherence on anxiety and depression in patients with hereditary cancer: a study of patients’ sense of coherence 6 months after genetic counseling. Journal of Genetic Counseling. 2007;16(5):607–615.
CrossRef
Tiikkainen and Heikkinen, 2005. 60.Tiikkainen P, Heikkinen RL. Associations between loneliness, depressive symptoms and perceived togetherness in older people. Aging and Mental Health. 2005;9(6):526–534. MEDLINE |
CrossRef
Travis et al., 2004. 61.Travis LA, Lyness JM, Shields CG, King DA, Cox C. Social support, depression, and functional disability in older adult primary-care patients. American Journal of Geriatric Psychiatry. 2004;12(3):265–271. MEDLINE |
CrossRef
Tseng and Wang, 2001. 62.Tseng SZ, Wang RH. Quality of life and related factors among elderly nursing home residents in southern Taiwan. Public Health Nursing. 2001;18(5):304–311. MEDLINE |
CrossRef
Waite et al., 1999. 63.Waite L, Grayson D, Jorm AF, Creasey H, Cullen J, Bennett H, et al. Informant staging of dementia using the clinical dementia rating. Alzheimer Disease and Associated Disorders. 1999;13(1):34–37. MEDLINE |
CrossRef
Ware, 2005. 64.Ware JE. SF-36 Health Survey Manual and Interpretation Guide. Boston: Medical Outcomes Trust; 2005;. Ware and Sherbourne, 1992. 65.Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care. 1992;30(6):473–483. MEDLINE |
CrossRef
Ware et al., 1994. 66.Ware JE, Gandek BIQOLA Project Group. The SF-36 health survey: development and use in mental health research and the IQOLA project. International Journal of Mental Health. 1994;23(2):49–73. Weiss, 1973. 67.Weiss RS. Loneliness The Experience of Emotional and Social Isolation. Cambridge: MIT Press; 1973;. Weiss, 1974. 68.Weiss RS. The provisions of social relationships. In: Rubin Z editors. Doing Unto Others. Englewood Cliffs, NJ: Prentice-Hall; 1974;p. 17–26. Weiss, 1987. 69.Weiss RS. Reflections of the present state of loneliness research. In: Hojat M, Crandall R editor. Loneliness, Theory, Research, and Applications. Newbury Park, CA: Sage; 1987;p. 1–16. Wong et al., 2007. 70.Wong ST, Yoo GJ, Stewart AL. An empirical evaluation of social support and psychological well-being in older Chinese and Korean immigrants. Ethnic Health. 2007;12(1):43–67. Yeh et al., 2003. 71.Yeh SH, Lin LW, Lo SK. A longitudinal evaluation of nursing home care quality in Taiwan. Journal of Nursing Care Quality. 2003;18(3):209–216. MEDLINE a Faculty of Health and Social Sciences, Bergen University College, Haugeveien 28, N-5005 Bergen, Norway b Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway c Section for Epidemiology and Medical Statistics, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway d Centre for Clinical Research, Haukeland University Hospital, N-5021 Bergen, Norway e Section for Geriatric Medicine, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway f NKS Olaviken Hospital for Old Age Psychiatry, N-5306 Erdal, Norway  Corresponding author at: Faculty of Health and Social Sciences, Bergen University College, Haugeveien 28, N-5005 Bergen, Norway. Tel.: +47 55 585589; fax: +47 55 585556.
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