Social Relations and Health Assessments Among Older People: Do

Journal of Gerontology: SOCIAL SCIENCES1997. Vol. 52B. No. I. S27-S36

Copyright 1997 by The Geronlological Society of America

Social Relations and Health AssessmentsAmong Older People: Do the Effects of Integration

and Social Contributions Vary Cross-Culturally?

Ya-ping Su and Kenneth F. Ferraro

Department of Sociology and Gerontology Program, Purdue University.

Research on health assessments has shown the importance of social relations as a factor influencing health, especiallyamong older people. Drawing upon sociological theories of social integration and social exchange, this researchexamines two domains of social relations which are expected to influence assessed health. In addition, the study uses across-national sample (N = 3,407) of noninstitutionalized older people from the Republic of Korea, Fiji, Malaysia,and the Philippines to determine if modernization conditions the relationships between social relations and health.Results indicate that social integration has a positive effect on subjective health assessments in all nations, whereassocial contributions are significant only in Korea. Findings suggest that health assessments by elders in the mostmodernized nations appear to be much more influenced by the contributions they make to the social order than is thecase in nations which are less modernized.

HEALTH has long been interpreted as a state of completephysical, mental, and social well-being and not merely

the absence of disease or infirmity (World Health Organiza-tion, 1958). In order to capture this overall state of healthreflecting morbidity, function, and well-being, researchershave often turned to self-assessments of health as one of themost parsimonious and reliable indicators available (Engleand Graney, 1986; Idler, 1993; Idler and Kasl, 1991).Despite the limitations inherent in a single item to measure acomplex concept, it remains one of the most valuable indica-tors of health and predictors of health service use andmortality (e.g., Idler and Angel, 1990; Rakowski, Mor, andHiris, 1991; Wolinsky and Johnson, 1992). Indeed, Lange(1986) proposed that subjective evaluation of health is acombination of both illness and role performance reflectingthe dominant concepts in the medical and social functioningmodels of health and illness.

While self-assessed health continues to be widely usedand command the attention of researchers, relatively littleattention has been given to how social context and socialrelations may affect health assessments. There is a substan-tial literature on the subject of social relations as protectiveof health, the majority of which emphasizes the finding thatsocial support leads to better health (Berkman, 1984; Gott-lieb, 1981; Goudy and Goudeau, 1981; Kaplan etal., 1977;Stevens, 1992). Nevertheless, some empirical evidence hasshown that social support may also bring negative effects tohealth because of ineffective "help," excessive help, andunwanted or unpleasant interactions (Krause, 1995; Rookand Pietromonaco, 1987).

Research on how social relations may influence healthassessments, beyond the effects due to morbidity and func-tion, suggests that people who are dissatisfied with theirsocial relations actually rate their health poorer (AuslanderandLitwin, 1991; Krause, 1987). In addition, Stoller( 1984)found that extensive informal assistance may have the unin-

tended effect of making health ratings more negative, pre-sumably because of the dependency in the relationship. Theevidence is increasingly clear that social relations influencehealth assessments, but the mechanisms of the influence arestill unclear. This study seeks to contribute to our under-standing of social relations and health assessments amongolder people in two ways. First, drawing from two sociologi-cal theories, we examine if and how two salient dimensionsof social relations affect health assessments. Second, whilevirtually all studies are conducted within one country, thepresent research is cross-cultural. Drawing from moderniza-tion theory, samples of elders from four Western Pacificnations are used to determine if social integration and socialcontributions influence the way older people assess theirhealth. We first consider the research literature in light oftwo major sociological theories and then turn to moderniza-tion theory for specifying anticipated effects in a cross-cultural context.

Theoretical BackgroundTwo theories are considered helpful for better explicating

the possible relationships between social relations and healthassessments in this research: social integration and socialexchange. Durkheim's (1951 [1897]) theory of social inte-gration revealed the importance of social relationships suchas marriage, parenthood, religious involvement, and em-ployment for promoting well-being (i.e., reducing suicide)by providing a sense of meaning and purpose in life.Durkheim pointed out that social integration creates a set ofconstraints or controls on individual behavior such that thetraditional and stable rules of conduct characteristic of so-cially cohesive groups give members a sense of certainty andpurpose in living. Although integration in social groups maynot always promote health, from this perspective, it isusually better to be integrated than isolated. Social integra-tion often leads to social support, thereby protecting the

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S28 SU AND FERRARO

person against the uncertainty and despair that may lead todisordered functioning (Thoits, 1982).

Social integration theory, therefore, focuses on the waysin which social linkages and social networks may control orregulate an individual's behavior or thoughts and feelings inways that generally promote better health or well-being.Social integration, as defined by House, Umberson, andLandis (1988), refers to "the existence or quantity of socialties or relationships, which may in turn be distinguished as totype (e.g., marital, kin/nonkin) and frequency of contact. Aperson's degree of social integration/isolation is a functiononly of the number of relationships s/he has with otherpeople or the frequency of interaction with those people'' (p.302; emphasis in original). It is important from an integra-tion perspective to gauge the sociometric linkages individ-uals have, for these are seen as pivotal in shaping health andmorale. Previous research generally shows that structuralproperties are important, but more consequential to healthand well-being are the content of those relations (Krause,1987, 1995; Seeman, Seeman, and Sayles, 1985; Stoller,1984). For the present study, therefore, we hypothesize thatamong persons with similar levels of health status, socialintegration will independently affect health assessments.Although social integration may have positive or negativeeffects on health, we hypothesize that social integration willbe associated with more favorable evaluations of health.

The second theoretical perspective considered is socialexchange theory, which views social life as analogous toeconomic transactions and shares many tenets with behav-ioral psychology. "Any action provides some rewards andentails some costs. Rewards can assume many forms includ-ing not only money, goods, and services, but also prestige,status, and approval by others" as people attempt to "maxi-mize rewards and minimize costs" (Michener, DeLamater,and Schwartz, 1986, p. 13). In addition, social exchangetheory maintains that people will establish stable relation-ships only if they find it profitable to continue their exchangeof goods and/or services. An individual judges the attractive-ness of a relationship by comparing the profits it providesagainst the profits available in other, alternative relation-ships. The profit available in the best alternative relationshipis termed the individual's comparison level for alternatives(Blau, 1964; Thibaut and Kelley, 1959).

It is quite common that people entering advanced old agetend to become more dependent on others helping them withactivities of daily living or health maintenance functions(Dowd, 1975). After a lifetime of typically giving more toyounger persons than they received from them, elders mustincreasingly come to accept beneficence; for parents, thebeneficence most often comes from children (Dowd, 1984).This is difficult for many, despite the fact they have estab-lished a "social credit" from past contributions, becausethey may have less to offer to balance the relationship. Inother words, their growing dependency on adult childrenmay make them feel awkward. In such cases, it is possiblethat in addition to the actual health problems influencinghealth assessments, the awkwardness of continually receiv-ing beneficence without being able to contribute meaning-fully to social relationships may make them more negativeabout life and their health. The key issue appears to be what

the older person can contribute to a relationship to foster asense of reciprocity.

While several studies have examined help given to theelder (e.g., Brackbill and Kitch, 1991; Langer, 1990; Wen-towski, 1981), according to exchange theory, help given byelders may be more important for understanding how theyfeel about themselves and life. If they give to the relation-ship, they are probably more independent, but if they givelittle to the relationship, social dependency may be morelikely. Therefore, we hypothesize that among persons withsimilar levels of functional health status, elders who contrib-ute more to their social networks will more positively assesstheir health. (There is also the possibility that high levels ofsocial contributions may be associated with poorer healthratings because of feelings of uncompensated exchanges.We hypothesize the positive effect but will conduct two-tailed tests.) Although it may risk oversimplification, socialintegration theory focuses on how structural linkages in-fluence outcomes, while social exchange theory focuses onhow contributions to the networks are consequential.

Most of the literature on social relations and health assess-ments comes from single-nation studies, many of themsurveying Americans. Still, there are other investigationswhich examine these issues in Canada (McDaniel andMcKinnon, 1993) or other developed nations such as France(Grand et al., 1988, 1990), Japan (Sugisawa, Liang, andLiu, 1994), Israel (Auslander and Litwin, 1991), Poland(Synak, 1987), and Sweden (Hanson et al., 1989; Mullins,Sheppard, and Andersson, 1991). Most of these studiesshow that older people who are less integrated assess theirhealth more negatively (Auslander and Litwin, 1991; Mul-lins, Sheppard, and Andersson, 1991; McDaniel andMcKinnon, 1993). Despite these single-nation studies, weare unaware of any comparative studies related to this topic.Social integration theory was developed after the industrialrevolution, in part, because many social linkages weresubstantially altered by modernization. Social exchange the-ory is even more recent, and it is conceivable that theutilitarian emphasis of the perspective may make its applica-tion more appropriate for modern societies. There is a dearthof research on how social relations affect health status andhealth assessments in less developed nations, let alone com-parative studies. Yet, different social and cultural contextsmay shape the way social relations influence health andhealth assessments.

Modernization theory asserted that elders' status is gener-ally higher in the less developed nations (Cowgill, 1986;Cowgill and Holmes, 1972) and, with the exception ofsimple nomadic societies, some empirical research supportsthis assertion (e.g., Cox, 1990; Palmore and Manton, 1974).On the other hand, there is a substantial literature fromanthropologists, historians, and sociologists showing thatmodernization theory oversimplified the "plight" of olderadults (Haber and Gratton, 1994). For instance, the declinein status for older people may have actually preceded mod-ernization and been caused by cultural change, not industri-alization (Fischer, 1977; Haber, 1983). Despite these limita-tions of modernization theory for specifying causalmechanisms, it may be useful as a heuristic framework forhypothesizing associations between social relations, mod-

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SOCIAL RELATIONS AND HEALTH ASSESSMENTS S29

ernization, and orientations to health. If elders are morerevered in traditional cultures — especially the Asian cul-tures studied here — one might hypothesize that contribu-tions to the social order to maintain reciprocity will be lessimportant in the traditional nations, where elders' status isgenerally higher than in modern nations. We would alsoexpect social integration to be greater in less developednations and characterized by more proximate and enduringties. Thus, one might hypothesize that social integration inless developed nations will have a stronger effect on healthassessments than would be the case in more developednations. The rationale for this expectation is that people onthe low end of the integration distribution in traditionalsocieties would feel slighted in comparison to their peers(while limited integration in modern societies may seem lessimportant). Of course, this is an empirical question andintegration effects may vary by type (e.g., family vs associa-tions). Given the lack of previous cross-cultural research onthe topic, the present investigation seeks to enhance ourunderstanding of how social relations affect health assess-ments by considering older adults from four Western Pacificnations at various stages of modernization. To summarize,we anticipate that social integration's effect on health assess-ments will be stronger in traditional societies, but that theeffect of social contributions on health assessments will bestronger in more modern societies.

METHOD

SamplesData for this research came from the 1983-1985 survey,

Social and Health Aspects of Aging in Fiji, Korea, Malaysiaand the Philippines, sponsored by the World Health Organi-zation. This cross-national survey was conducted in 1984and obtained interview responses from 3,577 individuals.Although the survey was conducted a decade ago, its suit-ability for cross-national comparison and tests of socialtheories of aging make it unique for this study.

The same questionnaire was used to sample older peopleliving in households in all four countries. To improve com-prehension and validity of the questionnaire across differentcultures, the questionnaire for each nation was translatedinto the language and dialect, and back-translated into En-glish to compare the differences and minimize problemsassociated with cultural differences (Andrews, 1986). Dif-ferent sampling designs were used for each country, andresponse rates were generally quite high — over 90%,except for the urban Philippines sample (Metro Manila),which had a response rate of 83.5%.

The samples in the Republic of Korea (n = 981) and Fiji(n = 769) were designed to cover the entire countries andrandom samples were applied, while in Malaysia (n =1,000) the survey included only Peninsula Malaysia, wherepurposive sampling was used. In the Philippines (n = 981),the Tagalog region of Luzon (21 % of the Philippine popula-tion) was sampled with a three-stage stratified cluster design.The samples, except in Fiji, were weighted to be viewed asrepresentative of the populations for these areas for personsaged 60 years and older, by sex, and by rural and urbanresidence (Andrews, 1986).

Esterman and Andrews (1992) show that living arrange-ments in the four countries are fairly similar: respondents"lived in households which had an average size rangingfrom 5.1 persons in Malaysia to 6.0 in the Philippines" (p.276). There were relatively few elders who lived alone inthese four countries. The percentage of elders living aloneranges from 2.0 in both Fiji and the Philippines to 5.7 inMalaysia. As suggested by Esterman and Andrews (1992),this is in direct contrast to the situation in most Westernnations, where up to 60 percent of elderly people live alone.In fact, elderly people in the Western Pacific region arealmost twice as likely to live in extended households as theirEuropean counterparts (Andrews, 1986). (In the U.S., 42%of elders aged 65 and over lived alone in 1990, 33% livedwith a spouse, and only 13% lived with a relative other than aspouse [U. S. Bureau of the Census, 1991].)

Despite the similarities in living arrangements, there isconsiderable variability among the four nations. Table 1profiles the four nations on 11 ecological indicators reflect-ing state of modernization. The Republic of Korea is clearlythe most modernized of the four, especially evident onindicators of energy consumption, telephones, TV, andphysicians per capita. The Philippines is probably the leastmodernized of the four, with Fiji closer to the Philippinesand Malaysia more similar to South Korea.

The analysis is based on a sample of 3,407 noninstitu-tionalized respondents: 969 Malaysians, 806 Filipinos, 713Fijians, and 919 Koreans. Approximately 58 percent of allrespondents are female. The average age for all respondentsis 70.24; Korean and Malaysian respondents are slightlyolder than Filipinos and Fijians. Although three of thesamples were weighted to assure accurate representation,some caution is warranted when combining the surveysbecause of bias due to different sampling designs.

MeasuresThe surveys asked a number of questions that were related

to the concepts under investigation: health assessments, func-tional health, social integration, social contributions, andstatus characteristics. Except for the status characteristics,multiple measures for each concept were available. Theanalysis began by creating a series of additive indexes withthe items for the indexes selected based on extant researchand theory (Fillenbaum, 1988; House, Umberson, and Lan-dis, 1988; Wilson and Cleary, 1995). All of the healthmeasures had very solid alpha reliabilities, but one of thethree measures of social relations had a reliability below .60and one below .70. Therefore, factor analyses were used tooptimize the linear relationship among the items. The resultspresented below are derived from principal components fac-tor analysis with an oblique rotation, but similar results werealso obtained from factor analysis with unweighted leastsquares estimation procedures. The same sets of items wereidentified in the factor analyses as were specified a priori.

Health. — A total of 13 survey questions were used tomeasure various dimensions of health status (Wilson andCleary, 1995). These included 2 questions on the subjectiveevaluation of health and 11 questions on functional healthstatus. The first dimension of functional health, physical


S30 SU AND FERRARO

Table 1. Modernization Indicators in the Four Nations

Indicator

Life expectancy (1982/1992)Infant mortality rate per 1000 (1982/1992)"% of urban population'% of older population (age 65 and over)bc

GNP per capita (1992 U.S. $)•Energy consumption per capita (KG)bc

Telephones per capita (per 100 persons)''TV per capita (per 100 persons)1"% of labor force in agriculturebcd

Physicians per capita (per 10,000 personsin 1985/1993 Y

Literacy ratebc

Republic of Korea

1980

67.730.056.9

3.7162014226.5

16.446.5

7.287.5

1990

70.912.872.14.5

5450193611.219.421.0

10.590.0

Malaysia

1980

68.028.034.6

3.616908383.37.5

49.0

3.153.5

1990

70.814.043.0

3.7236010665.7

14.034.8

4.165.0

Fiji

1980

69.031.038.72.5

17505385.8

NA46.0

4.364.0

1990

71.523.044.0

2.918605467.01.4

44.0

4.980.0

The

1980

61.851.037.42.9

6503161.32.1

50.2

1.582.5

Philippines

1990

65.040.042.7

3.47302181.33.6

47.0

1.288.0

•World Tables. 1994. Baltimore and London: The Johns Hopkins University Press."The New Book of World Rankings. 1984. New York: Facts on File.'World Alias 2 & U.S. Atlas 2 for Macintosh. 1992. Navato, CA: Electromap.'Social Indicators of Development. 1995. Baltimore and London: The Johns Hopkins University Press.

activities of daily living (ADLs), was defined by the follow-ing items: ability to eat, to dress and undress, to take care ofone's appearance, to walk, to get in and out of bed, and totake a bath or shower. Responses were coded unable (0),able with help (1), and able without help (2). (See Fillen-baum's [1988] Multidimensional Functional Assessment ofOlder Adults). The second dimension, labeled instrumentalADL (IADL), was denned by the following items: ability toget to places out of walking distance, to go shopping for foodand clothes, and to handle money. The third dimension offunctional health, sick days, was composed of two items: (1)how many days respondents were so sick that they could notcarry on usual activities — such as going to work or workingaround the house, and (2) how many days in the last monththe respondent was in a hospital for physical health prob-lems. The distributions for these two items were groupedinto five categories ranging from none (coded 5) to 22-31days (coded 1). (All health items were coded so that highvalues reflect better health.)

Self-assessed health was based on two items: "How doyou feel about your present health: do you feel quitehealthy?" Responses were yes and no, coded 2 and 1,respectively. The second question was very similar to thewidely used self-rating of health: How would you evaluateyour present health; is it: (5) very good, (4) fairly good, (3)average, (2) fairly bad, (1) bad? The factor based on thesetwo items is the dependent variable for the analysis. Adescription of all variables in the analyses for each countryand the four countries together is presented in Table 2 withranges of variables, means, standard deviations, and factorloading scores where appropriate. (Factor variables are pre-sented in the first row of each block.)

Social relations. — Seventeen indicators of social rela-tions were examined in the preliminary analyses. By exam-ining the distribution for each item, the correlations amongthe items, and properties of alternative additive indexes, atotal of 10 items on social relations were selected for further

analyses. These were identified as indicators of three dimen-sions of social relations: social contributions, integration involuntary associations, and integration in family and friendnetworks (House, Umberson, and Landis, 1988). Additiveindexes were created for these three domains in preliminaryanalyses, but the index for social contributions had an alphareliability less than .60. In order to optimize the linearrelationship among the items, factor analysis was used (thefactor pattern that emerged was identical to that specifiedearlier). As shown in Table 2, social contributions gaugehow much help an elder provided. Whereas beneficence forelders in these four countries is typically high, at least higherthan in the West, higher levels of help provided probablyindicate a balance in exchange relations. The three itemsprobe help offered in both family and community relations.

Integration in voluntary associations was based on threeitems: (1) whether the respondent belongs to a social group;(2) the respondent's degree of participation (a leader, active,some, or no participation); and (3) whether the respondentbelongs to a group for elderly people. Integration withfamily and friends was constructed from four items: (1) howoften the respondent attends family functions; (2) how oftenrespondent sees relatives; (3) number of people respondentknows well enough to visit; and (4) whether the respondentsees family and friends frequently enough. While the fourthitem is a more subjective indicator than the other three, it isuseful as an indicator of perceived integration. (Also, corre-lations between it and the other three are similar to thoseamong the other three.) Missing data in small proportions onthe social relations indicators were recoded to the mean forrespondents from each country (Hertel, 1976).

Status characteristics. — The measurement of other vari-ables is fairly straightforward and is depicted in Table 2.Each of the status characteristics considered has been shownin previous research to be important in predicting healthassessments.



Table 2. Descriptions of Variables for the Four Nations (N = 3,407)

Variable

Health AssessmentHealth ratingFeeling healthy

Functional HealthADL

EatsDressesAppearanceWalksBedBath

1ADLGets to placesGoes shoppingHandles money

Sick daysDays sickDays in hospital

Social ContributionsLooks after childrenHelps make family decisionConsults re community

problem

Social IntegrationVoluntary Associations

Belongs to social groupGroup participationBelongs to group for elderly

Family and FriendsTimes attends family

functionsFrequency sees relativesNumber knows to visitSees family and friends

enough

Status CharacteristicsSexHousehold membersAgeEducation

Range

1 = bad, 5 = very good1 = no, 2 = yes

0 = unable, 2 = no help0 = unable, 2 = no help0 = unable, 2 = no help0 = unable, 2 = no help0 = unable, 2 = no help0 = unable, 2 = no help

0 = unable, 2 = no help0 = unable, 2 = no help0 = unable, 2 = no help

1 = 22-31 days, 5 = 0 days1 = 22-31 days, 5 = 0 days

0 = otherwise, 1 = yes0 = otherwise, 1 = yes

0 = otherwise, 1 = yes

0 = otherwise, 1 = yes0 = none, 3 = leader0 = otherwise, 1 = yes

1 = once a year, 7 = daily1 = once a year, 7 = daily0 = none, 3 = 5 +

0 = otherwise, 1 = yes

0 = female, 1 = male0-8 (0 = 0, 8 = 8 +)59-1100 = 0, 6 = 17+ years

4-NationsMean (SD)

-.013.341.66

-.121.971.961.951.891.931.93-.051.621.641.76-.014.754.94

.00

.56

.70

.32

-.01.21.26.10.00

3.094.042.20

.60

.424.49

70.241.12

(1.53)(1.08)

(.46)

(4.09)(19)(•23)(.24)(.35)(.30)(.29)

(2.14)(.58)(.62)(.51)

(1.37)(.77)(.35)

(1.36)(.50)(.46)

(.47)

(2.03)(•40)(.63)(.30)

(1.89)

(1.27)(1.68)

(.99)

(.50)

(.49)(2.41)(7.48)(1.33)

Republicof Korea

Mean (SD)

-.543.001.49

-.461.971.951.931.871.871.86-.041.591.651.76-.114.634.93

-.13.53.64

.32

.08

.27

.45

.26-.86

3.123.671.66

.34

.374.41

71.23.67

(1.77)(1.28)

(•50)

(3.97)(.18)(.23)(.27)(.38)(•40)(.37)

(2.31)(.64)(.63)(.57)

(1.06)(.93)(.36)

(130)(.50)(.48)

(.47)

(2.72)(.44)(.78)(.44)

(1.83)

(1.33)(1.42)(1.00)

(.47)

(.48)(2.08)(6.98)(119)

MalaysiaMean (SD)

.133.401.71

.291.961.961.971.941.961.95.40

1.661.701.67.12

4.834.96

-.39.51.62

.16

-.22.23.16.05.31

2.994.022.36

.78

.404.03

70.73.71

(1.43)(.99)(.45)

(3.80)(.22)(.24)(.23)(.28)(.22)(.27)

(2.04)(.54)(.60)(.54)(.84)(.71)(.34)

(1.24)(.50)(.49)

(.37)

(1.56)(.42)(.47)(.21)

(1.83)

(1.41)(1.56)

(.95)

(.41)

(.49)(2.64)(8.10)(1.08)

FijiMean (SD)

-.113.331.59

-.481.941.941.921.801.921.93-.041.541.561.65-.144.654.89

.84

.68

.77

75

.18

.28

.36

.05-.33

3.013.352.24

.58

.525.07

69.441.54

(1.46)(1.02)(.49)

(4.74)(•26)(.28)(.31)(.46)(.33)(.32)

(2.38)(.63)(.72)(.59)

(1.10)(.86)(.44)

(1.33)(.47)(.42)

(.43)

(2.02)(•45)(.74)(.21)

(1.88)

(1.28)(1.77)

(.95)

(.49)

(.50)(2.39)(7.29)(1.33)

PhilippinesMear

.533.651.84

.111.971.951.961.891.961.95.16

1.631.581.92.10

4.844.95

-.13.55.80

.11

-.86.03.05.01.91

3.225.122.57

.68

.404.64

69.201.70

i(SD)

(1.13)(.84)(.37)

(3.86)(.20)(.26)(.24)(.34)(.23)(.25)

(1.78)(.54)(.59)(30)(.73)(.59)(.26)

(1.17)(.50)(.40)

(.31)

(.86)(.18)(.34)(.11)

(1.49)

(.95)(1.48)

(.77)

(.47)

(.49)(2.37)(7.25)(1.36)

FactorLoadingScores

.90046

.93242

.75171

.91801

.90091

.53076

.73419

.76633

.86025

.89972

.71816

.72700

.89150

.68301

.72687

.60758

.86269

.87340

.72108

.67689

.73313

.67405

.65308

Note: The elements in the first row of each block are means and standard deviations for each factor variable.

Causal FrameworkThe issue of reverse causality between health and social

relations merits consideration in the analysis and interpreta-tions. While Durkheim's thesis stresses the role of integra-tion on health and well-being, certain dimensions of healthmay affect social integration. In particular, functional dis-ability may limit some types of integration. Sensitivity tothis issue is important while interpreting the findings, but thefocus of this research is on how social relations affect healthassessments after controlling for functional disability. Inaddition, careful examination of the social relations indica-tors shows that most are oriented to belonging or socialcontributions based on advisory roles (e.g., family sage) andare not directly hinged on functional ability.

RESULTS

A series of hierarchical regression analyses were per-formed to estimate the relationships between self-assessedhealth and the predictor variables (Ordinary Least Squares:OLS). We first examine the relationships among all coun-tries together, including dummy variables for three of thefour nations. Next, we examine whether the relationships aredifferent across the four nations by analyzing each nationseparately (i.e., test for statistical interaction). Table 3presents unstandarized and standardized regression coef-ficients along with both R2 and adjusted R2 values for thehierarchical models estimated on all countries simultane-ously. (Although the measure of health assessment used is aconstruct of two items, supplementary analyses using or-


S32 SU AND FERRARO

Table 3. Ordinary Least Squares (OLS) Regression Estimates of Equations Predicting Health Assessment (N = 3,407)

Variable

Functional HealthADLIADLSick days

Status CharacteristicsSex (male)AgeEducationHousehold members

Social Contributions

Social IntegrationVoluntary associationsFamily and friends

Countries'MalaysiaFijiThe Philippines

Intercept

Rl

Adjusted R2

Model I

b Beta

.05** .12

.19** .26

.20** .17

.00

.16

.16

Model

b

.05**

.18**

.19**

-.13*.00.17**.02

-.52

.18

.18

II

Beta

.12

.25

.17

-.04.02.15.03

Model

b

.05**

.18**

.19**

-.14**.01.16**.01

.06**

-.55

.19

.18

III

Beta

.12

.24

.17

-.04.03.14.02

.05

Model

b

.05**

.15**

.19**

-.13**.01.15**.01

-.01.13**

-.58

.21

.20

IV

Beta

.11

.21

.17

-.04.03.13.02

-.02.16

Model

b

.05**

.15**

.19**

-.13**.01.14**.01

.04*

-.02.13**

-.60

.21

.21

V

Beta

.11

.21

.17

-.04.03.12.03

.04

-.02.16

Model

b

.04**

.16**

.18**

-.13**.01**.09**.01

.06**

.03*

.07**

.53**

.38**

.83**

-1.14

.24

.23

VI

Beta

.10

.22

.16

-.04.04.08.01

.06

.04

.09

.16

.10

.23

Note: b = unstandardized, Beta = standardized regression coefficients."Korea serves as the reference group.*p< .05;**p < .01.

dered logistic and ordered probit models for self-rated healthyielded very similar results.)

Model I simply uses the functional health measures topredict health assessments. Sixteen percent of the variance isaccounted for by ADL, IADL, and sick days alone. Takingstatus characteristics into consideration, as shown in ModelII, females and more educated elders are more likely to reportpositive health while there are no differences by age andhousehold size. Model III adds the variable measuring socialcontributions and reveals that elders who are providing helpto their families or communities are more likely to reportgood health. Model IV substitutes social integration for socialcontributions and shows that integration in voluntary associa-tions is nonsignificant, but integration in family and friendnetworks contributes to better self-assessed health. The ef-fects of all variables are quite similar in Model V, whichincludes both social contributions and social integration.

Model VI adds three dummy variables (0,1) for thecountries, with Korea serving as the reference group. Re-gression slopes for Malaysia, the Philippines, and Fiji showthat elders in these three nations are more likely than Koreanelders to favorably evaluate their health status, even aftercontrolling for all other variables. Among these three na-tions, respondents from the Philippines assess their healthmost favorably followed by Malaysia and Fiji. (A glanceback at Table 2 shows Malaysian elders with the best healthbased on ADL, IADL, and sick days, but Filipinos assesstheir health more favorably in the multivariate analysis.)There is little change in the effects of the independentvariables in Model VI, except that voluntary associations has

a weak positive effect. The findings are consistent withprevious research in the U.S. showing that women, theoldest elders, and those with higher education are morelikely to have positive health assessments (e.g., Cockerham,Sharp, and Wilcox, 1983; Ferraro, 1980; Fillenbaum,1979). Overall, Model VI explained nearly one-fourth of thevariance in assessed health; the R2 value is comparable to thatreported by others on U.S. samples (Idler and Angel, 1990;Rakowski and Cryan, 1990; Seeman, Seeman, and Sayles,1985). As hypothesized, social integration and social contri-butions positively affect health assessments.

Supplementary analyses treating the indicators of socialcontributions separately reveal that the more an elder canhelp to make family decisions, the more likely the elderpositively evaluates his or her health. On the other hand,help looking after children and consultation regarding com-munity problems were nonsignificant in predicting healthassessments.

Country-Specific Regression AnalysisAs the regression equation for Model VI of Table 3

suggests, there are differences among countries in self-assessed health. We can also see the difference between self-assessed health, functional health, voluntary associations,family and friends, and social contributions among the fourcountries in Table 2. Therefore, country-specific OLS regres-sion analyses were conducted to test for different associationsbetween the predictor variables and outcome variable for eachcountry. Moreover, in order to see if there is interactionbetween countries and other predictor variables, models were



estimated separately for each country. Rather than simplycomparing slopes, tests of differences of slopes (t- value) werecalculated according to the following formula:

MSE\ + SE\

where b refers to the unstandardized coefficient and SE refersto the standard error of b (Marascuilo and Levin, 1983, p.101). Table 4 presents unstandarized coefficients, standard-ized coefficients, standard error of regression coefficients,and R2 values for each country. Standardized coefficients areprovided for interpretations within a given country butshould not be used for cross-national comparisons. As be-fore, Korea serves as a reference group for the analysis ofdifferences in slopes.

In Korea, all forms of social relations affected healthassessments and each effect is in the hypothesized direction.Social relations appear to most affect the health interpreta-tion process in the most modernized of the four countries. Asmentioned earlier, according to modernization theory, wehypothesized that contributions to the social order will beless important in the less developed nations and more impor-tant in more modernized nations. In the country-specificanalyses, we find that Korea, as the most modern nation inthe analysis, is the only nation where social contributions aresignificant in affecting elders' health assessments. Culturalimages of productivity and the ability to contribute to familyor society apparently influence self-assessments of healththrough the exchange process.

Results for Malaysia indicate that functional health status,education, and interaction in voluntary associations andfamily and friend networks significantly affect assessedhealth. The t-values for age and for voluntary associations

reflect interactions: the oldest elders in Korea are morefavorable in evaluating their health but this is not the case inMalaysia; integration in voluntary associations in Malaysiais negatively related to health assessments, but it is posi-tively related in Korea.

The regression model for Fiji shows that functional healthhas a significant influence on elders' health assessments, butthe effect of sick days is not as strong as in Korea. Womenand those with more education rate their health more favor-ably. Better assessed health is also found among elders withhigher levels of voluntary association integration. An inter-action between social contributions and country suggeststhat, unlike Koreans, social contributions do not influencehealth assessments among Fijian elders.

Finally, in the Philippines, the youngest and least modern-ized of the four countries, social contributions do not signifi-cantly affect health assessments. While social contributionshave a substantial positive effect on subjective health assess-ments among Korean elders, no such effect is present amongFilipinos (and the respective slopes are significantly differ-ent). Examining other contrasts for the Philippines andKorea shows that IADL and age contribute less to healthassessments in the Philippines. The only variables whichsignificantly influence assessed health among Filipinos arethe functional health indicators and integration in family andfriend networks.

DISCUSSION

This research was designed to contribute to our under-standing of how social relations influence the health interpre-tation process. The two major aims identified were to exam-ine (1) how two important domains of social activity affectself-assessed health among older adults, and (2) whether

Table 4. Country-Specific OLS Regression Analyses Predicting Health Assessment

Variable

Functional HealthADLIADLSick days

Status CharacteristicsSex (male)AgeEducationHousehold members

Social Contributions

Social IntegrationVoluntary associationsFamily and friends

Intercept

R2

Republic of Korea*(« =

b

.05**

.24**

.34**

.10

.03**

.08-.04

.19**

.05*

.10**

-2.34

.24

= 919)

Beta

.10

.26

.20

.03

.11

.06-.04

.15

.07

.09

SE

.02

.03

.05

.11

.01

.05

.03

.04

.02

.04

b

.03*

.20**

.30**

-.16.00.15**.01

.08

-.07*.13**

-.18

.18

Malaysia(n =

Beta

.06

.22

.17

-.06.01.12.01

.05

-.07.13

969)

SE

.02

.03

.05

.10

.01

.04

.02

.06

.03

.03

f

-.71-.94-.57

-1.75-2.12**

1.091.39

-1.53

-3.33**-.60

b

.04**

.16**

.20**

-.30**.01.13**.01

.03

.08**-.01

-1.05

.17

Fiji(« =

Beta

.13

.26

.15

-.10.07.12.01

.02

.10-.01

713)

SE

.01

.03

.05

.11

.01

.04

.02

.07

.03

.04

/"

-.45-1.89-1.98**

1.29-1.41

.78-1.39

-1.98**

.83-1.94

b

.05**

.12**

.23**

-.05-.00

.03

.02

-.02

.03

.14**

.40

.20

The Philippines(« =

Beta

.13

.23

.15

-.02-.01

.03

.05

-.01

.02

.15

806)

SE

.01

.03

.05

.08

.01

.03

.02

.05

.05

.03

r"

0-2.83**-1.56

-1.10-2.12**

-.861.66

-3.28**

-.37.80

Note: b = unstandardized, Beta = standardized regression coefficients."Korea serves as the reference group.'Value of t; the differences of slopes between countries was calculated by using Korea as reference group.*p< .05;**p< .01.


S34 SU AND FERRARO

these relationships vary cross-culturally. We are unaware ofany study in the literature which has combined these scien-tific aims.

The two domains of social relations considered weresocial integration and social contributions in social ex-changes. While previous research suggested the importanceof each, most studies suggested that content of relations andactive contributions to relations would be more important(Krause, 1987; Stoller, 1984). In the cross-cultural analysisundertaken, only social integration was found to be animportant influence on health assessments in all countries.Integration in family and friend networks aided health as-sessments in Malaysia, the Philippines, and Korea whileintegration in voluntary associations had a positive effectonly in Fiji and Korea. Unexpectedly, voluntary associationintegration had a slight negative effect on health assessmentsin Malaysia, perhaps because of the unique character ofvoluntary associations oriented to needy elders there. What-ever the case, there is ample evidence of the importance ofsocial network integration in shaping health assessments,consistent with social integration theory (Durkheim, 1951[1897]; House, Umberson, and Landis, 1988; Thoits, 1982).The significant effect is always positive for these countrieswhen it comes to integration in family and friend networks.The effects due to voluntary association integration aregenerally weaker, but positive in two out of the four nationsand negative in only one. While some caution is neededwhen generalizing regarding modernization from just thesefour nations, it appears that voluntary association integrationis least consequential — either positive or negative — whenthe level of modernization is low (i.e., the Philippines).

While it has received previous little attention in surveyresearch, we also considered elders' contribution to others insocial exchanges. Despite hypothesizing that such contribu-tions would favorably influence health evaluations, thisrelationship was observed only among people of the Repub-lic of Korea, the most modernized nation of the four. Thisprovides some support for social exchange theory becausethe content of exchanges, in addition to structural properties,also affect health assessments (Krause, 1987; Stoller, 1984).However, this relationship was not observed in any of theother, less modernized nations. Thus, it appears that contri-butions to the social order are more important in modernizedsocieties, presumably because productivity is valued more.If elders contribute to exchange relationships in modernsocieties, their health assessments, and we may speculatemorale, are more favorable. On the other hand, in moretraditional societies, perhaps especially traditional Pacificand Asian societies, structural integration is sufficient tobolster health assessments in the face of poor functionalhealth, and social contributions do not further aid subjectivehealth.

Evaluating one's health status does not occur in a socialvacuum; and the health interpretation process is shaped notonly by physical health problems and status characteristicsbut by social status, structure, and participation. The lack ofan effect on health assessments due to contributions to thesocial order among three of the four countries should cer-tainly not be interpreted as a refutation of social exchangetheory. There is clearly a need for further research on how

levels of modernization influence health interpretations, andthe measures of social relations available in this survey arelimited. Yet, the findings presented here should temperassertions about the role of reciprocity when beneficence toelders is normative, especially in less developed countries oreven in subcultural contexts. Structural integration was im-portant to health interpretations across all societies consid-ered here, but the importance of elders actively contributingto the social order was consequential in the most modernsociety only: Korea. In summary, we hypothesized thatmodernization should increase the impact of social contribu-tions on health assessments, and these results confirm thathypothesis. We also hypothesized that modernization shoulddecrease the impact of social integration on health assess-ments, but there is insufficient evidence to support thishypothesis: integration was influential in all four countries.

Age differences in health assessments have also attractedattention among researchers because they are not alwaysintuitively understood. There is an emerging body of litera-ture in the United States that the oldest members of the seniorpopulation do not always have more negative health ratingdespite their higher levels of morbidity and functional limita-tion (e.g., Cockerham, Sharp, and Wilcox, 1983; Ferraro,1980; Idler, 1993). Parallel to these findings, the presentstudy also finds that the oldest members of the seniorpopulation in Korea are more positive in evaluating theirhealth after controlling for functional health status. Ofcourse, the flip side of this interpretation is that the youngermembers of the elderly population are somewhat pessimisticin evaluating their health. As we observed this effect onlyamong the Korean elders suggests, once again, that culturalimages constructed from productivity and retirement may bepart of the reason researchers have observed a more negativetone in health interpretations among those close to, ap-proaching, or recently entering the "retirement years."

This research is not without its limitations. First, forMalaysia and the Philippines, the surveys cover only selectedregions of the nation whereas for Korea and Fiji, the surveyscover the entire country. This is not a serious flaw given thecomparative emphasis here and the dearth of related research,but it does constrain external validity for those two nations.Second, no measures of morbidity were available in thesurvey. While the three sets of indicators of functional healthexplain respectable levels of variance in health assessments(similar to reports by Idler and Angel, 1990; Rakowski andCryan, 1990; Seeman, Seeman, and Sayles, 1985), we wouldhave preferred to include morbidity indicators in the analysis.Of course, measuring morbidity across cultures is no simplematter given differences in actual morbidity as well as liter-acy, educational attainment, and cultural definitions of ill-nesses. Whereas our hypotheses focused on the role of socialrelations, adequate measures of functional health are evenmore important given the correlation between the two. Never-theless, the absence of indicators of morbidity merits cautionwhen interpreting the results. Third, the analysis did notexamine the possibility of reciprocal linkages between socialrelations and health assessments. Although the findings in thestudy suggest that social relations have a positive effect onhealth assessments, it is also possible that better health leadsto stronger social integration and social contributions. Defini-



tive tests of such interpretations, however, are not generallyfeasible with cross-sectional data. Fourth, because differentsampling designs are used in the four nations, some caution isneeded regarding external validity. Finally, the measures ofsocial contributions are limited. Contributions to family in-come and wealth were not measured, but may be important aswell.

Despite the limitations, this is the first study of which weare aware that examines the contributions of social relationsto the health interpretation process in a cross-cultural frame-work. The data clearly show the importance of social rela-tions influencing health assessments above and beyond ef-fects due to functional health and status characteristics.Social integration has a salubrious effect in all four nations,but contributions to the social order influence health assess-ments only in the most modernized nation. The findingssuggest not only that social life is important to healthinterpretation but that the social status of elders and norms ofbeneficence, reflected in these four cultures, are also impor-tant when older people seek to classify their state of bodilyfunction and overall health.

ACKNOWLEDGMENTS

An earlier version of this study was presented at the 1996 annual meetingof the Midwest Sociological Society, Chicago. Support for this researchwas provided by the National Institute on Aging (AG-11705). The datawere made available by the Inter-university Consortium for Political andSocial Research. Neither the collector of the original data nor the consor-tium bears any responsibility for the analyses and interpretations presentedhere. We appreciate the helpful comments of James G. Anderson, DinnieChao, Ralph Cherry, Anthony Lemelle, John Stahura, Janet Wilmoth,Chao Xu, Yan Yu, and the anonymous reviewers.

Address correspondence to Dr. Kenneth F. Ferraro, Department ofSociology, Stone Hall, Purdue University, West Lafayette, IN 47907-1365.E-mail: [email protected]

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Received October 30, 1995Accepted July 31, 1996


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