Journal of Gerontology: PSYCHOLOGICAL SCIENCES1996, Vol. 5IB, No. 5, P268-P278

Copyright 1996 by The Gerontological Society of America

The Importance of Friendship and Family Supportin Adaptation to Chronic Vision Impairment

Joann P. Reinhardt

The Lighthouse Inc., Arlene R. Gordon Research Institute, New York.

The importance of friendship and family support in adaptation for 241 elders experiencing age-related vision loss wasexamined. Adaptation was operationalized with two global measures of psychological well-being (life satisfaction,depressive symptoms) and a domain-specific measure, adaptation to vision loss. Hierarchical regression analysestested the effects of sociodemographic, vision, health, and functional disability variables in the first step, familysupport quality in the second step, and friendship support quality in the third step. Variables entered at each stepcontributed significant portions of explained variance in outcome variables. Thus, the importance of friendshipsupport, independent of family support, in adaptation to chronic impairment was demonstrated. The effect ofrelationship type and gender on multiple support components was also assessed. Scores for family support were higherthan those for friend support on almost all components. Close relationships were perceived as providing greaterattachment in females and greater instrumental assistance and social integration in males.

DEALING with chronic physical impairment and its re-sulting disability becomes more normative in later life,

especially for women (Penning & Strain, 1994). The studyof adaptation to the stressor of physical impairment anddisability is especially important in elders because of itsimpact on life satisfaction and depression (Gurland, Wilder,& Berkman, 1988; Williamson & Schulz, 1992). One dif-ficulty in describing the complex process through whichsuccessful adaptation is facilitated is that some of the priorresearch in this area is based on samples that are heteroge-neous with respect to the life events or stresses experienced(Cutrona, Russell, & Rose, 1986). In the current study ofsupport in disabled elders, the stressor of chronic physicalimpairment was exemplified by age-related vision loss,which varies in severity and requires great functional, psy-chological, and social adjustment in elders who have beensighted until late life.

Vision impairment has been identified as the second mostcommon cause of disability for persons aged 65 and above(Ford, Folmar, Salmon, Medalie, Roy, & Galazka, 1988).This does not refer to normal changes in vision with age, butto vision impairment resulting primarily from age-relatedeye disease, which causes functional limitations and cannotbe corrected with refraction, medicine, or surgery. The mostrecent data from The Lighthouse National Survey on VisionLoss (1995), based on multiple indicators of functionalvision problems, indicate that as many as 17% of all middle-aged and older Americans self-report a vision impairment.The prevalence of vision impairment increases with age.Fifteen percent of individuals 45-64 years, 17% of thoseaged 65-74 years, and 26% of those 75 years old and olderself-report a vision loss (The Lighthouse Research Institute,1995). The characteristics of the vision loss itself (e.g.,peripheral or central field loss, lens opacity) are variable andoften multiple, depending on the type and severity of age-related eye disease experienced. The major types of eye

disease causing vision impairment in elders include senilemacular degeneration, glaucoma, and cataracts (Podgor,Lesley, & Ederer, 1983). Most visually impaired elders havesome degree of partial vision as opposed to being totallyblind. Vision impairment, which is strongly associated withdifficulty in performing daily living activities, has beendemonstrated to be an independent, significant predictor offunctional disability in elders after controlling for age, gen-der, and comorbidity (Horowitz, 1994; LaForge, Spector, &Sternberg, 1992).

The experience of vision loss in old age often results indepression, decreased morale, lowered self-esteem, andfeelings of excessive dependence (Branch, Horowitz, &Carr, 1989; Gillman, Simmel, & Simon, 1986). Successfuladaptation includes learning compensatory skills, renegoti-ating supportive relations, and maintaining mental health.Social support has been demonstrated to be a critical factorin adaptation to stress in elders. The experience of visionimpairment and disability is likely to alter the need forpsychosocial and material resources from elders' socialnetworks. Family members and significant others can playan important role in elders' adaptation, such as providingencouragement for the initiation and completion of rehabili-tative services (Lindenberg, 1980; Moore, 1984). Alter-nately, significant others can be overprotective and actuallypromote the development of excessive disability (Moore,1984). Overall, the dynamics of support use are clarifiedwhen people experience major life crises and transitionssince support is most likely to be needed and accepted underthese circumstances (Albrecht & Adelman, 1987).

The Role of Friendship and Family Supportin Adaptation to Chronic Impairment

While the linkage of stress, social support, and mentalhealth is well established in the gerontological literature(e.g., George, 1989; Kessler & McLeod, 1985), comparison

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of the amount and the effect of support received fromspecific sources within the broad context of social supporthas received less attention. Although the informal supportnetwork of elders includes family members, friends, andneighbors, friends have long been described as an underuti-lized resource for elders (Cantor, 1979). Family membersare prominent in the study of elders' support relationships,while the support from non-kin relations is often overlooked.While it is not suggested that age peers can replace familymembers, especially in the role of caregiver for frail elders,they do play an important role as providers of a combinationof multiple support components in later life (Antonucci,1990; Shea, Thompson, & Blieszner, 1988). For example,research has shown that while family members are mostoften the providers of instrumental support to elders, friendsalso provide instrumental support to both relatively healthy(Reinhardt & Fisher, 1988) and chronically impaired elders(Roberto, 1992). The finding that friends are most willingand able to meet such needs when they are relatively lessextensive (Cantor & Little, 1985), does not diminish theimportance of their support.

The role of friend, defined by its voluntary nature, affec-tive base and mutual choice, can be lifelong. Many eldersmaintain friendships through advanced old age, often overmany decades (Blieszner, 1989; Johnson & Troll, 1994).Close friends may help each other come to terms with thefailing health and chronic disability that may be experiencedin old age. Research has demonstrated that friendship isincreasingly important for physically impaired persons (Ad-ams, 1986; Lubben, 1989). Friends, who are usually similarin terms of gender, social class, marital status, and age group(Dono, Falbe, Kail, Litwak, & Sherman, 1979), seem wellsuited to provide help in the socialization to age-relatedchange such as learning new roles or relinquishing old roles.Further, friends, who are often age peers, may provide aunique sense of ego support and reaffirmation of an individ-ual's personal worth in later life (Cantor, 1979). The studyof multiple support sources of elders who are experiencingthe stressor of late life chronic physical impairment, includ-ing both kin and non-kin relations, is critically important.

Theoretical guidance regarding the study of kin and non-kin support providers is provided by Weiss's (1974) theoryof social provisions. Weiss maintains that individuals re-quire six key social provisions, which include bothassistance-related (reliable alliance, guidance) andnonassistance-related components (social integration, reas-surance of worth, nurturance, and attachment) in order tomaintain well-being and to avoid loneliness. These compo-nents, provided by primary group relationships (character-ized by closeness, warmth and commitment), supply distinc-tive benefits. For example, an individual lacking attachmentwould experience emotional isolation, while someone lack-ing social integration would experience social isolation.Considered together, these components provide an assess-ment of total perceived support quality.

Weiss (1974) holds that relationships tend to becomespecialized in their provisions and, as a result, individualsmust maintain a number of different relationships for well-being. Some of these provisions are typically provided bykin and others are typically provided by friends. Reliable

alliance (instrumental support) is most often provided bykinship relations, which are based on a sense of affiliation.Weiss states that instrumental support is often provided bykin regardless of the level of mutual affection or whether onehas reciprocated for past help. Guidance, especially impor-tant in times of stress, is provided by significant others whoare seen as trustworthy and authoritative. Friendships offerprovisions associated with a community of interest such associal integration. Reassurance of worth is provided byrelationships that support a person's competence in a socialrole, such as colleagues in the workplace or family membersin the home. Opportunity for nurturance is provided by arelationship in which the individual takes responsibility forthe well-being of another, such as a child. Attachment-providing relationships tend to be an exception where spe-cialization is concerned. The marital relationship is definedby its sense of attachment, but attachment can also beprovided by other relationships with family members orclose friends.

Overall, rather than designating which person will satisfya specific need, Weiss's (1974) model holds that multipleneeds must be satisfied by one's support network. Moreover,he notes that there is probably an element of almost everyrelational provision in each supportive relationship. Weiss'stheoretical model has received substantial empirical support(Cutrona & Russell, 1987; Felton & Berry, 1992; Mancini &Simon, 1984).

It should also be stressed that gender seems to be adifferentiating factor in describing adult friendships, withdifferences between women and men in the utilization andeffect of supportive relationships (Wright, 1989). Womentend to have more intimate friendships than men, who seemto focus their friendships around activities (e.g., An-tonucci, 1990). Furthermore, while women are likely tohave a female friend as a confidant, men are more likely torely on their spouse as a confidant, and thus confine emo-tionally supportive interaction to their wives (Hess &Soldo, 1985). These gender differences are characteristicthroughout the life span and they continue throughoutadulthood into old age (Wright, 1989). They do not, how-ever, negate the importance of friendship for the psycholog-ical well-being of older men. It is important to include bothwomen and men in research examining friend and kinsupport providers in later life.

In addition to the differential function of family andfriendship relations, research has examined the effect ofthese relations on psychological well-being. There seems tobe more solid empirical evidence of a positive relationshipbetween friendship support and well-being than family sup-port and well-being in elders (Peters & Kaiser, 1985). Thesefindings are intriguing given the major role of the family inthe lives of elders, especially as providers of instrumentalsupport. Focusing on the differential nature of friendship asoptional and family relations as obligatory, Antonucci andJackson (1987) have suggested that these relationships arejudged by different standards. While family members areobligated to provide support in times of need, supportprovided by friends is optional and thus particularly appreci-ated when received. Larson, Mannell, and Zuzanek (1986)found that, in comparison with family members, the unique

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qualities of friendship interactions including openness, reci-procity, and positive feedback along with the spontaneousaffection and joy inherent in friendship interaction werepartly responsible for the link between friendship relationsand subjective well-being in elders.

Study Purpose and OverviewIn this study of friendship as a resource for older females

and males who are adjusting to late life chronic visionimpairment, friendship is studied in the context of familysupport. Separate assessment of friend and family supportpermits the investigation of a differential effect of supporttype on multiple outcome variables. Elders have relation-ships with kin and friends at varied levels of affectivecloseness (Antonucci, 1990). Given the importance of close,primary relationships for the receipt of support components(Albrecht & Adelman, 1987; Cantor, 1979; Weiss, 1974),this research assesses the amount of support chronicallyimpaired elders perceived from their closest family memberand their closest friend. The primary focus of this study is totest the hypothesis that total perceived friendship supportadds unique variance to adaptation after accounting for totalperceived family support. While the focus is on friendshipand family support, sociodemographic variables that havebeen demonstrated to be related to adaptive status in later lifeare also assessed. These variables include gender, age,marital status, living arrangements, education, and socio-economic status. Because of the importance and multiplefunctions of spousal relationships, a dichotomous variablewas created to indicate whether or not the closest familymember described by participants was a spouse. Otherpredictor variables that were examined include vision status,health status, and functional disability. The degree of thevision disability has been identified as a potential predictorof adaptation, although empirical findings have been incon-sistent. There is some evidence that degree of residual visionis related to well-being and adaptation to vision loss(Schultz, 1977). However, other work has found that neitherthe suddenness of onset of the vision loss, nor the degree ofimpairment, influences adaptation (Horowitz, Reinhardt,Mclnerney, & Balistreri, 1994). Because dealing withchronic physical impairment and resulting disability be-comes more normative in later life, self-rated physical healthand functional disability are included as predictor variables.

Three measures of adaptation to chronic impairment areutilized. While measures of subjective well-being addressthe broad concept of adaptation to later life, this researchfocused on adaptation to a specific chronic impairment.Thus, adaptation is assessed with both domain-specific (ad-aptation to vision loss) and global indicators (life satisfactionand depressive symptoms). Global indicators of both posi-tive and negative aspects of adjustment are used given theorthogonal nature of these outcome variables. Thus, assess-ment of a differential effect of family and friendship varia-bles on multiple adaptation variables is possible.

While total support scores will be used in analyses toexamine the effects of kin and non-kin support, an additionalfocus of this study is to examine support components byrelationship type and gender. Specific hypotheses, based onWeiss's (1974) theoretical model, were formulated to guide

these analyses. Regarding relationship type, two main ef-fects are expected with scores for instrumental assistancehigher for family support than friend support, and socialintegration higher for friend support than family support inelderly females and males. Regarding relationship type andgender, two interactions are expected. Specifically, it isexpected that for friendship support, attachment scores willbe higher for women than men, and social integration scoreswill be higher for men than women.

METHOD

ParticipantsStudy participants were 343 community-residing females

(n. = 188) and males (n = 155) who ranged in age from 65to 100 (M age = 79.22; SD = 7.34), who experienced age-related (rather than lifelong) vision loss. A 100% sample ofparticipants was taken as cases were closed at a visionrehabilitation service agency serving both urban and subur-ban populations. While 93% (n = 318) of the originalsample had a close family member, just over three quartersof respondents, 77% (n = 264), had a close friend. Whilefemales (10.6%) were significantly more likely than males(3.2%) to be lacking a close family member (\2[1, n = 343]= 6.91, p < .01), there were no significant gender differ-ences in the proportion of respondents who lacked a closefriend (20.7% of females and 25.8% of males). Only tworespondents lacked both a close friend and a close familymember. Because the focus of this research is on examiningthe unique effect of friendship support on adaptation afteraccounting for family support, the analyses described in thisreport were conducted on the subsample of elders who hadboth a close friend and a close family member, that is, 70%(N = 241) of the original sample.

A comparison was conducted between the 241 elders inthe subsample and the remaining elderly participants (n =102) on several major variables. Results demonstrated thatsubsample participants were significantly younger, with bet-ter self-rated health and less functional disability than elderswho were not in the subsample. The two groups of elders didnot differ by gender, marital status, or education, and theydid not have significantly different scores for vision lossseverity, life satisfaction, depressive symptoms, or adapta-tion to vision loss.

In the subsample of 241 elders, 130 were female, 111were male, and age ranged from 65 to 99 (M age = 78.60;SD = 7.14). Most participants were Caucasian (85%), withat least a high school degree (65%), and without a spouse(58%; including 44% widowed, 7% divorced or separated,and 7% never married), although only 39.8% lived alone.Participants were normally distributed among the five SEScategories of the four-factor Hollingshead Index. All respon-dents experienced "low vision," that is, some degree ofvision impairment that is not correctable by refraction,medicine, or surgery (Faye, 1984). As expected, the mostcommon eye diseases reported involved age-related eyedisease. Forty-eight percent reported having macular degen-eration, 38% had cataracts, and 26% reported having glau-coma. Just under one half of respondents (48.5%) reported

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that they had more than one vision problem. Most respon-dents (76%) indicated that they had experienced a gradualrather than a more sudden vision loss, which is typical ofage-related vision impairment.

Characteristics of Closest Family Memberand Closest Friend

Since perceived support measures focused on each re-spondent's closest friend and closest family member, demo-graphic characteristics of these two persons were examined.The age of closest family members ranged from 27 to 94,with an average age of 60.50 (SD = 15.54). The relation-ship type of the closest family member was almost equallydivided among spouses (32.8%), children (38.2%), andother relatives (29%). Male respondents (50.5%) were morelikely than females (17.7%) to describe their spouse as theirclosest family member, and females (43.1%) were morelikely than males (32.4%) to describe a child as their closestfamily member (x2[2,N = 241] = 31.46,/? < .001). Not allmarried respondents chose their spouse as their closestfamily member. Nearly one third (30.3%) of the 33 marriedfemales and 20.3% of the 69 married males selected otherrelatives as their closest family member (percentages did notdiffer significantly).

The age of closest friends ranged from 30 to 99 with anaverage age of 70.01 (SD = 12.31). While the majority ofrespondents (88.4%) reported same-gender friendships,more males (21.6%) than females (3.1%) reported cross-gender friendships (x2[l, N = 241] = 20.05, p < .001).The number of years respondents maintained their friend-ships ranged from 1 to 72 with an average of 28.18 years (SD= 18.69). There were no gender differences in this variable.Only 17% of respondents reported that they had maintained arelationship with their closest friend for less than 10 years.

Measures

Sociodemographic variables. — Single-item indicatorswere used to assess gender, age, marital status, education,and living arrangements. Socioeconomic status was assessedwith the Hollingshead 4-factor index of social position(Hollingshead, 1975).

Vision status and health status. — The Functional VisionIndex (Horowitz, Teresi, & Cassels, 1991) was used as asubjective indicator of vision loss severity. Items assessfunctional vision problems (e.g., Does trouble with yourvision make it difficult for you to read medicine bottlelabels?; When you are walking in the street, can you read thestreet name signs?). Possible scores range from 1 to 15. Ahigh score indicates high vision loss severity. Comorbidphysical health status was assessed with a single-item ratingon which respondents rated their health on a 5-point scaleranging from poor (5) to excellent (1). A high score indicatespoor overall health status.

Functional disability. — A modified version of the OARSMultidimensional Functional Assessment Questionnaire(Center for the Study of Aging and Human Development,1975) was used to assess functional disability in everyday

tasks. The modification involved the addition of 4 items thataddress specific functional tasks that may be affected byvision loss, including identifying clothing, coins, bills, andthe food on one's plate, and the ability to travel in unfamiliarplaces. Seven personal tasks (sample a = .82) and 11instrumental tasks (sample a = .88) were assessed, and acombined index of 18 personal and instrumental tasks ofdaily living was created (sample a = .89). Items werescored on a 3-point scale: (0) does task with no difficulty; (1)does task with difficulty; (2) needs help/cannot do task.Possible scores range from 0 to 30. A high score indicateshigh functional disability.

Social support network: Size and contact frequency. —Respondents were asked to list the number of family mem-bers (children, siblings, and other close relatives) and closefriends they had as a measure of kin and friend socialnetwork size. "Close" was defined as, "persons you feelclose to, that you feel at ease with, can talk to about privatematters, or can call on for help." The frequency of bothtelephone and in-person contact (on a 6-point scale rangingfrom [0] never see to [5] every day) with both respondents'family network members and close friends was also as-sessed. Scores were summed for in-person and telephonecontact. Possible scores range from 0 to 30 for familycontact and 0 to 10 for friend contact.

Friendship support quality. — To assess friendship sup-port quality, respondents were first asked to think of thefriends they feel close to. Of this group, they were asked tochoose the one friend they feel closest to, defined as, "theone friend (nonrelative) with whom you feel the most at ease,can talk to about private matters and/or to whom you usuallyturn first when you need some help." The 24-item SocialProvisions Scale (SPS; Cutrona & Russell, 1987), based onWeiss's (1974) theory of social provisions, was used as amultidimensional measure of perceived support quality fromrespondents' closest friends. In addition to the work of thescale authors, this theoretically validated scale has beenempirically validated by other researchers (e.g., Mancini &Blieszner, 1992). While the SPS is commonly used to assessthe perceived quality of support the individual receives fromhis or her support network, without identification of networkmembers, the SPS has also been used as a source-specificassessment of support components (Cutrona, 1989; Felton &Berry, 1992). The SPS assesses six support components,including two assistance-related components: reliable alli-ance (termed "instrumental assistance" hereafter; e.g., "Ican count on this person to help me if I really need it") andguidance (advice/information; e.g., "I can talk to this per-son about important decisions in my life") and four non-assistance-related components. The latter include attach-ment (e.g., "I feel a strong emotional bond with thisperson"), reassurance of worth (acknowledgment of compe-tence; e.g., ' 'This person admires my talents and abilities"),social integration (group belonging, shared interests; e.g.,"This person enjoys the same social activities I do") andnurturance (feeling that one is needed by others; e.g., "I feelthat this person relies on me for his/her well-being"). Itemsare scored on a four-point Likert scale (strongly agree to

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P272 REINHARDT

strongly disagree). Possible component scale scores rangefrom 4-16. The scale also yields an overall measure ofsupport (sample a = .88; component scale scores aresummed) as well as six subscale scores. Possible scores fortotal support quality range from 24-96 with high scoresindicating high support quality.

Family support quality. — The closest family memberwas chosen the same way as the closest friend. Respondentsanswered the same series of questions described above fortheir closest family member (sample a = .89 for totalsupport quality). The order of these two sections of thequestionnaire was counterbalanced across participants.

Descriptive characteristics of closest friend and closestfamily member. — Descriptive information was obtainedfor respondents' closest friend and closest family memberincluding age, the relationship type of the closest familymember, the gender of the closest friend, and the number ofyears respondents have maintained a relationship with theirclosest friend.

Adaptation. — Two indicators of global adaptation wereused. The 18-item version (Adams, 1969) of the Life Satis-faction Index-A (LSI-A) was used as a measure of psycho-logical well-being (Neugarten, Havighurst, & Tobin, 1961;sample a = .82). The LSI-A has a possible score range of 0to 18 with high scores indicating more positive well-being.The 20-item Center for Epidemiological Studies DepressionScale (CES-D) was used as a measure of depressive symp-tomatology (Radloff, 1977; sample a = .90). The CES-Dhas a possible score range of 0 to 60 with high scoresindicating high depressive symptoms. For the CES-D, eldersreported the frequency with which they experienced depres-sive symptoms during the previous week.

One indicator of domain-specific adjustment, the 24-itemAdaptation to Age-Related Vision Loss Scale (AVL; Horo-witz & Reinhardt, 1993), was used to assess adaptation tovision loss. The AVL scale is a unidimensional scale withitems assessing three general content areas: the extent towhich the person accepts vision loss in a realistic manner;whether the person has a positive and optimistic attitudetoward the importance and potential for learning new skillsthat compensate for vision loss; and whether the person has apositive outlook toward continuing relationships withsighted family and friends, neither rejecting assistance whenneeded nor becoming excessively dependent upon others.Respondents are asked whether they agree or disagree witheach item. Sample items include, "Because of my visionloss, I feel like I can never really do things for myself; I donot want to be around my sighted friends anymore becausethey will feel sorry for me; There are worse things that canhappen to a person than losing vision; I feel comfortableasking my family arid friends for help with things I can nolonger do because of my vision loss." Psychometric analy-ses of the AVL scale indicate high internal consistency(sample a = .87) and evidence of convergent validitythrough significant correlations of the AVL scale with mea-sures of life satisfaction and depression (Horowitz &

Reinhardt, 1993). Possible scores range from 0 to 24, withhigh scores indicating more successful adaptation to age-related vision loss.

ProceduresParticipants were first contacted by letter, and then

follow-up telephone calls were made to schedule appoint-ments with interested persons. A 60% response rate wasobtained. Elders were interviewed in their homes with astructured questionnaire (M = 93.12 minutes; SD = 25.21)by trained interviewers. Respondents gave written, informedconsent for participation after the study procedures wereexplained, and they received $10 for participating in theresearch.

RESULTS

Gender Differences in Major VariablesBefore conducting primary analyses, major variables

were examined by gender for descriptive purposes. Analysisof demographic variables by gender revealed that comparedto male respondents (M age = 77.27; SD = 7.11), females(M age = 79.73; SD = 7.00) were significantly older(f[239] = 2.70, p < .01), and less likely to live with aspouse (25.4%) than males (62.2%; x

2 [ l , N = 241] =33.18, p < .001). Similarly, females (50.8%) were morelikely to live alone than males (27.0%; x2D, N = 241] =14.08, /? < .001). Finally, females had less education thanmales (x2[6, N = 241] = 31.60, p < .001), and lowersocioeconomic status (x2[4, A = 240] = 13.97, p< .01).

Data on social network structure indicated that respon-dents had an average of 3.45 (SD = 3.06) persons in theirclose friend network and 5.49 (SD = 4.07) persons in theirfamily network. Gender differences were found for friendnetwork size, with males (M = 3.94, SD = 3.57) reportinga slightly higher number of close friends than females (M =3.03, SD = 2.48; t[\, 239] = 4.28, p< .05). Size of familynetwork was not significantly different by gender. Scores forfamily network contact ranged from 0 to 30 with an averagescore of 12.86 (SD = 5.82) and scores for close friendnetwork contact ranged from 0 to 10 with an average score of6.91 (SD = 2.63). There were no significant gender differ-ences in either of these two indicators of network contact.

Descriptive information for the total sample and by genderfor major study variables, including vision status, healthstatus, functional disability, total friendship support, totalfamily support, life satisfaction, depressive symptoms, andadaptation to vision loss is provided in Table 1. Genderdifferences were found for four of these variables. Com-pared to males, females had significantly greater vision lossseverity (?[239] = 2.73, p < .01), poorer self-rated health(t[231] = 2.81,/? < .01), lower life satisfaction (f[239] =-2.56, p < .01), and more depressive symptoms (t[237] =2.81, p< .01).

Correlational AnalysesIntercorrelations of all major variables were initially com-

puted separately by gender and transformed to Fisher z's totest for significant differences. Results demonstrated that the

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intercorrelations among major variables were not signifi-cantly different for females and males (results not shown).As described earlier, three outcome variables were assessed,including life satisfaction, depressive symptoms, and adomain-specific indicator of adaptation to vision loss. Varia-bles representing each of five major conceptual categories ofpredictor variables (sociodemographic characteristics, vi-sion status, health status, functional disability, and socialsupport) were assessed for their correlation with each of thethree outcome variables. Individual variables examined in-clude gender, age, marital status, living arrangement (alone/with others), education, socioeconomic status, relationshiptype of closest family member (spouse/nonspouse), func-tional vision loss, self-rated health, functional disability,family network size, friend network size, family networkcontact frequency, friend network contact frequency, totalperceived support quality from closest family member, andtotal perceived support quality from closest friend. Thecriterion for including a variable in a regression equation wasthat it had a significant (p < .05) bivariate correlation withthe outcome measure of interest. The intercorrelation ofpredictor variables was also examined. A correlation matrixof the variables that are significantly associated with out-

come variables is presented in Table 2. A listwise correlationmatrix is utilized so that the cases correspond to those used inthe regression analyses.

It is important to point out that the more qualitative indexof social support, total perceived support quality from familymembers and friends, was significantly related to adaptationoutcome variables, whereas the quantitative indices of fam-ily and friend network size and contact frequency were not.Being male, younger, having better self-rated health, fewerfunctional vision problems, less functional disability, higherperceived support from one's closest family member andfrom one's closest friend were associated with greater lifesatisfaction and fewer depressive symptoms. Having ahigher educational status was also associated with fewerdepressive symptoms. Having a higher educational status,better self-rated health, fewer functional vision problems,less functional disability, higher perceived support fromone's closest family member and from one's closest friendwere associated with more positive adaptation to vision loss.

Hierarchical Regression AnalysesThree 3-step hierarchical regression analyses were con-

ducted, one for each of the outcome variables to test the

Table 1. Descriptive Statistics for Major Study Variables (N = 241)

Variable

Functional vision loss"Self-rated health"Functional disability"Total friendship support1*Total family support6

Life satisfaction6

Depressive symptoms"Adaptation to vision loss6

Range

1-151-5

0-3051-9353-96

0-180-483-24

Females

M

1J.692.70

10.6871.7175.95

9.0314.9317.86

SD

2.461.026.878.618.134.14

11.265.00

Males

M

10.732.338.98

71.2278.0010.3810.9318.25

SD

3.020.976.928.389.194.00

10.655.07

M

11.252.539.90

71.4976.91

9.6513.0718.04

Total

SD

2.791.016.938.498.684.12

11.145.03

"Higher scores indicate more negative status."Higher scores indicate more positive status.

Table 2. Intercorrelations of Study Variables8

Variable

1. Gender"2. Age3. Education11

4. Self-rated health0

5. Functional vision lossc

6. Functional disability*7. Total family support11

8. Total friend supportd

9. Life satisfaction"1

10. Depressive symptoms'11. Adaptation to vision lossd

1

-.16*26***

-.17**-.17**-.14*

.14*-.03

.15*_ |7**

.06

2

—-.05-.10

.01

.11-.14*_ 24***-.16*

.15*-.12

3

—-.21**-.11- .21***

.12

.08

.08_ 22***

.32***

4

—

.05

.29***- .21***-.16*_ 34***

33***_ 24***

5

—.46***

-.11-.07_ 3j***

.28***-.20**

6

—_23***_ 24***_ 4]***

42***

-.52***

7

—27***39***

-.31***26***

8

—31***

-.28***.32***

9

—_ 72***

49***

10

—-.54***

"Listwise correlations, n = 221."Female (1), male (2).'Higher scores indicate more negative status.dHigher scores indicate more positive status.*/;< .05;**/?< .01; ***/>< .001.

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hypothesis that friendship support adds unique variance toadaptation after accounting for family support. For each ofthese analyses, variables relevant to adaptation were en-tered in step 1, including sociodemographic factors, visionand health status, and functional disability. Total perceivedfamily support quality was entered in step 2, and totalperceived friendship support quality was entered in step 3.Regression results, presented in Table 3, display the stand-ardized Beta coefficients from the final step of each analy-sis, and the change in R2 and corresponding significancelevel from each step.

Results for life satisfaction demonstrated that the block ofsociodemographic, health, and functional ability variablesentered in step 1 significantly accounted for 28% of thevariance. In step 2, family support quality added a signifi-cant 5% to the total variance accounted for. Finally, friend-ship support quality, entered in step 3, added a significant2% to the total variance in life satisfaction. Thus, the eightpredictor variables significantly accounted for a total of 35%of the variance in life satisfaction. At the final step, fiveindividual variables accounted for statistically unique vari-ance in life satisfaction. Participants who had better self-rated health, better functional vision, less functional disabil-ity, higher total perceived support quality from closestfamily member, and higher total perceived support qualityfrom closest friend had greater life satisfaction.

For the regression analysis of depressive symptoms onpredictor variables, the block of variables entered in step 1accounted for 27% of the total variance. Family supportquality, entered in step 2, predicted an additional 2% of thevariance in depressive symptoms, and friendship supportquality, entered in step 3, accounted for an additional 1% ofvariance. Thus, 30% of the variability in depressive symp-toms was accounted for by these variables. At the final step,the same five variables accounted for unique variance indepressive symptoms (reverse relationship) as in the pre-vious analysis.

Results for the regression analysis of adaptation to visionloss on predictor variables demonstrated that the block of

variables entered in step 1 significantly accounted for 32% ofthe variance. In step 2, family support quality added a sig-nificant 2% to the total variance accounted for. Finally,friendship support quality, entered in step 3, added a signifi-cant 3% to the total variance in adaptation to vision loss.Thus, the six predictor variables significantly accounted fora total of 37% of the variance in adaptation to vision loss. Atthe final step, three individual variables accounted forunique variance in adaptation to vision loss. Respondentswith higher education, less functional disability, and higherperceived friendship support had higher adaptation to visionloss scores. While family support was significant in step 2, itdid not retain significance in the final step of the analysis.

Examination of Support Components by RelationshipType and Gender

While the focus of this study is on the effect of the totalperceived support received from the closest friend and theclosest family member, individual support components wereexamined to describe the nature of the perceived supportfrom these two providers in more detail. Because it is likelythat the multiple support components received from a re-spondent's closest family and friend are associated, a corre-lation matrix of the 12 support components was examined(see Table 4). Correlations ranged from .01 to .72 with thehighest associations found between guidance and attachmentand between guidance and instrumental assistance for bothfamily and friends. While similar intercorrelations havebeen reported by the authors of the social provision scales,empirical validation of subscales has also been provided(e.g., Cutrona & Russell, 1987).

The goal of these analyses is to demonstrate how thegroups defined by gender and relationship type (treated as awithin-groups factor) differed in perceived support compo-nents. A multivariate two-way analysis of variance(MANOVA) was used to evaluate this question as it con-siders the multiple interrelated dependent variables simulta-neously, without losing information concerning their jointrelationships. In order to interpret the MANOVA results,

Table 3. Hierarchical Regression Results for Variables Predicting Life Satisfaction, Depressive Symptoms, and Adaptation to Vision Loss

Variable

Step 1:GenderAgeEducationSelf-rated healthFunctional vision lossFunctional disability

Step 2:Total family support

Step 3:Total friend support

Total R2

Life Satisfaction

.03-.09

—_ 22***

-.18**-.18**

22***

.14*

(n = 230)

R2 Change

28***

.05***

.02*

35***

Depressive Symptoms

P'

-.03.09

-.07.21**.13*2i**

-.14*

-.12*

(n = 228)

R1 Change

27***

.02**

.01*

30***

Adaptation to Vision Loss(n

—

—20***

-.02.04

_ 43***

.10

.17**

= 227)

R2 Change

.32***

.02*

.03**

.37***

"Standardized Beta coefficient.*p< .05;**p< .01; ***/?< .001.

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FRIENDSHIPS AND FAMILY SUPPORT IN DISABLED ELDERS P275

Table 4. Intercorrelations of Support Variables8

Variable

1. FAMRA2. FAMGDE3. FAMATT4. FAMRW5. FAMSI6. FAMNUR7. FRDRA8. FRDGDE9. FRDATT

10. FRDRW11. FRDS112. FRDNUR

1

—

.61***

.63***

34***.12.31***.21**.06.19**.18**

-.07

2

—77***42***45***.0525***23***

.06

.14*

.15*-.09

3

—5Q***

43***.19**25***

.18**

.07

.20**

.18**-.10

4

—39***

.1229***23***

.19**43***27***

-.03

5

—.19**.07.05.04.16*.18**

-.09

6

—.04

-.03-.14*

.01-.07

20**

7

—.61***42***45***.37***.09

8

—.62***52***

.48***

.12

9

—45***47***

.20**

10

—4g***

.03

11

—.03

Notes: FAM = family, FRD = friend, RA = instrumental assistance, GDE = guidance, ATT = attachment, RW = reassurance of worth, SI = socialintegration, NUR = nurturance.

"Listwise correlations, n - 211; higher scores indicate higher support.*p< .05;**p< .01; ***/>< .001.

Table 5. Descriptive Information on Support Componentsby Relationship Type and Gender'

Table 6. Multivariate Effects for Social Support Componentsby Relationship Type and Gender

Instrumental assistance M

Guidance

Attachment

Reassurance of worth

Social integration

Nurturance

SDRange

MSDRange

MSDRange

MSDRange

MSDRange

MSDRange

"Female n = 111; male n = 100.

Friend

Female

13.28

2.216-16

13.052.14

7-16

12.802.10

7-16

12.991.77

8-16

11.942.12

6-16

8.422.26

4-16

Male

13.72

2.078-16

13.011.99

8-16

11.652.35

5-16

13.081.76

7-16

12.211.77

8-16

8.252.24

4-16

Family

Female

14.44

1.819-16

14.022.046-16

14.011.65

11-16

13.351.888-16

11.412.294-16

9.352.864-16

Male

14.86

1.508-16

14.311.93

7-16

13.932.14

8-16

13.321.94

9-16

12.142.50

6-16

10.253.03

4-16

Comparison

Family versus Friend"Instrumental assistanceGuidanceAttachmentReassurance of worthSocial integrationNurturance

Female versus Maleb

Instrumental assistanceGuidanceAttachmentReassurance of worthSocial integrationNurturance

Relationship type x Gender0

Instrumental assistance

GuidanceAttachmentnP!)cciif!)nrp Ai u/rtrtnixcadoUiallCC Ul will 111

Social integrationNurturance

Canonical

StructureCoefficient

.59

.52

.72

.18-.12

.51

-.28-.08

.41-.02-.30-.18

.02-.25-.72

19. 1 L.

-.31-.62

UnivariateF( 1,209)

53.41***42.34***80.43***4.94*2.39

41 13***

4.06*0.328.72**0.024.79*1.68

0.00

0.937.61**0 90\J. i*\J

1.415.51*

univariate Mests and F-ratios and canonical structure coef-ficients, which are Pearson product-moment correlationcoefficients between each dependent variable and the canon-ical variable (Tabachnick & Fidell, 1989), were obtained. Inthe MANOVA procedure, canonical dependent variables arecreated to maximize the differences between the indepen-dent variable groups (Tabachnick & Fidell, 1989). Thesecanonical coefficients are interpreted as loadings that can beused to make inferences about the relationship of eachsupport variable to the overall multivariate effects for thebetween- and within-group differences.

Descriptive statistics for support components are presentedin Table 5 and results for the MANOVA and follow-up

"exact F(6,204) = 8.57***, Wilks lambda = .80."exact F(6,204) = 25.33***, Wilks lambda = .57.'exact F(6,204) = 2.37*, Wilks lambda = .93.*p < .05; **p < .01; ***p < .001.

analyses are reported in Table 6. Results demonstrated a sig-nificant multivariate effect for gender, relationship type, andthe interaction of gender and relationship type. An examina-tion of the univariate F-ratios and the canonical structurecoefficients revealed that the significant multivariate effectfor relationship type is due to the higher support componentsof attachment, instrumental assistance, guidance, nurturance,and reassurance of worth for family members compared to

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P276 REINHARDT

close friends. The effect of attachment was especially strong.Only social integration failed to show a significant effect. Thecanonical structure coefficients and univariate results forgender reveal that the significant multivariate effect is largelyattributable to the higher support components of attachmentfor females, and social integration and instrumental assis-tance for males. The interaction between relationship typeand gender compared four groups: perceived friendship sup-port for females (n = 111), perceived family support forfemales (n = 111), perceived friendship support for males (n= 100), and perceived family support for males (n = 100).Results demonstrated that the multivariate effect for theinteraction between gender and relationship type is associatedwith the two support components of attachment and nurtur-ance. For attachment, the greatest mean differences werefound for friend support by gender. Females had higherscores than males for attachment from friends. For nurtur-ance, the most prominent mean differences were found forfamily support by gender. Males had higher scores thanfemales for nurturance from family members.

DISCUSSION

Study results demonstrated that the majority (70%) of theinitial sample of elderly, visually impaired women and menhad both a close friend and a close family member. While theresults of the analyses presented can only be generalized tosimilar elders, comparisons of support providers can only bemade if multiple providers exist. Examination of the charac-teristics of close friends and family members revealed thatwhile the relationship type of the closest family member wasvariable, males were more likely than females to choose aspouse. This finding is not unexpected, given that not onlyare males more likely than females to be living with aspouse, but also, previous research indicates that men aremore likely than women to view their spouse as their closestconfidant (Hess & Soldo, 1985). Regarding friendship,males were not more likely than females to be lacking a closefriend, but males did have more cross-gender friendshipsthan women. This finding is similar to that reported in priorresearch (e.g., Wright, 1989). The majority of each groupdid, however, have same-gender friendships. In addition,the friendships described were generally long-term relation-ships (average = 28 years) with age peers.

Results for hierarchical multiple regression analyses ex-amining the effect of kin and non-kin support on adaptationdemonstrated that similar portions of total variance wereaccounted for in each outcome variable. After accounting forfamily support, friendship support predicted unique variancein all three outcome variables. Visually impaired elders whomaintain supportive later-life friendships in addition to fam-ily relationships have higher life satisfaction, fewer depres-sive symptoms, and better adaptation to vision loss. Thisfinding is especially significant even though the portion ofvariance accounted for by support variables is not large. Asin prior research examining the predictors of late-life adapta-tion (e.g., Kennedy, Kelman, & Thomas, 1990), the largestportions of variance were accounted for by health andfunctional ability variables. While support variables areimportant for adaptation, it is not likely that they wouldaccount for equally large portions of variance. Regarding

health variables, it is important to point out that both visionstatus and comorbid health status, in addition to functionaldisability, contributed unique variance to life satisfactionand depressive symptoms. Thus, it is important to examinethe effect of both specific impairments (i.e., vision loss) andgeneral health status in addition to functional disability onlater life adaptation.

Overall, a similar pattern of results was found for the twoglobal adaptation variables, life satisfaction and depressivesymptoms. Thus, family and friendship support did not havedifferential effects on more positive versus more negativeindicators of adjustment. Results varied, however, for adap-tation to vision loss. Fewer variables accounted for uniquevariance in this outcome variable. Better adaptation to visionloss was associated with less functional disability, highereducation, and higher friendship support quality. This out-come variable was also the only one of the three that was sig-nificantly predicted by a sociodemographic variable. It isimportant for practitioners who work with visually impairedelders to know that low educational status is a significant riskfactor for poor adaptation to vision loss. It is interesting tonote the importance of friendship support quality for adapta-tion to vision loss as friendship, but not family supportquality, predicted unique variance in this outcome variablein the final step of the analysis. Finally, it is noted that whilefunctional disability predicted unique variance in adaptationto vision loss, vision and comorbid health status did not.Thus, the effect of chronic impairment on elders' functionalability is most important for domain-specific adaptation.This underscores the importance of rehabilitative interven-tions for specific chronic impairments that focus on therestoration or maintenance of some level of elders' func-tional abilities.

Finally, it is interesting to note that while bivariate com-parisons indicated poorer status for females compared tomales (e.g., less education, poorer health status, greatervision loss severity), gender did not predict unique variancein any of the outcome variables. Friendship and familysupport were significant for adaptation for both older womenand men. Overall, future work examining the effect ofsupport on adaptation to chronic impairment may accountfor more variability by examining additional aspects ofsupport such as an evaluation of support adequacy, and moreconflicting components of support such as overprotective-ness. Significant others may not only provide support, butalso be a source of conflict and disappointment. Researchevidence shows that negative exchanges with providers havean even greater effect on elders' well-being than positiveexchanges (Rook, 1990). As Rook has pointed out, assess-ment of positive aspects of one's support network does notnecessarily tell us anything about distress or tension alsocreated by the network.

Hypotheses regarding the effect of relationship type andgender on individual support components were largely sup-ported. Significant multivariate effects were found for rela-tionship type, gender, and the interaction of these twovariables. Follow-up analyses revealed that regarding effectsfor relationship type, as expected, scores on instrumentalassistance were significantly higher for family members thanfriends. In addition, all other support components, with the

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exception of social integration, were also significantlyhigher for family members than friends. While scores forsocial integration were not significantly higher for friendsthan family members, as expected, mean scores were in thepredicted direction. Thus, while some support was receivedfor predictions based on Weiss's (1974) theory, the primacyof family support — which has been stressed by theoristssuch as Cantor (1979) — is clear in these findings. It isimportant to remember that this research specifically di-rected respondents to describe a close friend and a closefamily member. While family support scores were signifi-cantly higher for all but one support component, componentscores for close friends were still relatively high.

Follow-up analyses regarding interaction effects revealedthat the hypothesis that friendship attachment scores wouldbe higher for females than males received support. In addi-tion, there was a significant main effect for attachment withfemales reporting higher scores than males for both familyand friend relationships. The hypothesis that males wouldhave higher friendship support scores than females for socialintegration received partial support as there was a significantmain effect for gender for this variable. Males had signifi-cantly higher scores than females for social integration inboth friend and family relationships. Thus, while femalesperceived more attachment from their close relationships,males perceived greater social integration from their closerelationships. These gender effects coincide with prior re-search in this area, and demonstrate that these effects areseen in both kin and non-kin relationships.

An additional significant interaction was found with malesreporting higher scores than females for nurturance (feel thatone is needed by others) from close family members. This isa reasonable finding, since more males than females de-scribed their spouse as their closest family member. Finally,an additional main effect for gender was found with malesreporting significantly higher scores for instrumental assis-tance than females for both friend and family support. Malesperceived the availability of a greater amount of instrumentalassistance from their close relationships. In sum, whileoverall perceived levels of kin and non-kin support did notvary by gender, examination of individual support compo-nents revealed several important differences.

Overall, there has been little empirical work regarding thefactors that predict better adaptation among older visuallyimpaired persons. This study has demonstrated the impor-tance of vision loss severity, comorbid health status andfunctional disability, along with sociodemographic factorssuch as education for adaptation to vision loss. Importantly,this study highlighted the unique importance of friendshipsupport after accounting for family support in adjusting tovision impairment. Descriptive information on support com-ponents showed that participants perceived greater supportfrom close family members than close friends. Yet, per-ceived friendship support played a significant role in theiradaptation to later life impairment.

One limitation of this research is its cross-sectional na-ture. Due to the dynamic nature of social relationships andthe complexity of the process of adaptation, longitudinalresearch is needed. The latter would be especially importantfor studying issues of substitution of kin and non-kin pro-

viders over time as one's relationship with particular pro-viders may change or terminate. Future research on adapta-tion to chronic impairment may gain a broader picture ofsupport utilization by examining the effect of support receiptover time and by examining the support of multiple pro-viders (not just elders' closest friend and family member).As Cantor (1979) has stressed, having a close relationshipwith support providers ensures meaningful support both intimes of crisis and on an ongoing basis. However, given theincreased support needs of chronically impaired elders,better adjustment may be associated with the ability to garnersupport from multiple network members regardless ofwhether the person is a confidant.

While a significant portion of variance in adaptationvariables was accounted for, future research may focus onthe identification and inclusion of additional factors that mayaffect adaptation to late life chronic impairment. As men-tioned previously, support can sometimes be a double-edgedsword (e.g., Antonucci, 1990; Rook, 1990); thus, the effectof negative aspects of support on elders' mental healthshould also be accounted for. In addition to social resources,future research should also examine the effect of personalresources such as coping strategies (Lazarus & DeLongis,1983) and perceived control (e.g., Krause, 1987; Schulz &Williamson, 1993) on adaptation outcomes. Also, the exam-ination of rehabilitative interventions on adaptation out-comes is important. For visually impaired elders, visionrehabilitation training can facilitate learning how to utilizeremaining vision to recover lost functional abilities (e.g.,learn to use the stove safely). Utilization of such servicesaffects life quality and promotes successful adaptation tochronic impairment (Horowitz et al., 1994). Examination ofpersonal and formal resources in addition to multiple socialresources received from multiple providers may provide aneven fuller picture of adjustment to chronic physical impair-ment in later life.

ACKNOWLEDGMENTS

This research was supported by National Institute of Mental Health grantR03 MH-46596.

Address correspondence to Dr. Joann P. Reinhardt, The Lighthouse Inc.,Arlene R. Gordon Research Institute, 111 East 59th Street, New York, NY10022-1202.

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Received July 5, 1995Accepted March 18, 1996

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