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RESEARCH ARTICLE |
a The Arthritis Community Research and Evaluation Unit, The University Health Network, Toronto, Ontario, Canada
b Department of Public Health Sciences, University of Toronto, Ontario, Canada
c Department of Physical Therapy, University of Toronto, Ontario, Canada
Monique A. M. Gignac, The Arthritis Community Research and Evaluation Unit, The University Health Network, PMH/OCI, 610 University Avenue, 16th floor Room 706, Toronto, Ontario, Canada, M5G 2M9 E-mail: gignac{at}uhnres.utoronto.ca.
Decision Editor: Toni C. Antonucci, PhD
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Abstract |
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CHRONIC illnesses that result in disability are often portrayed in terms of deterioration and loss. This is especially true of chronic illnesses and disabilities that occur in later life, because older adults are believed to have limited resources to manage their condition compared with younger adults (Becker 1993
). Moreover, research with older adults who have chronic health conditions has often centered around profoundly disabling conditions, such as strokes and cognitive impairments, such as Alzheimer's or Parkinsons disease. Fewer studies have examined the processes whereby older adults adapt to chronic physical illness and disability in an effort to maintain their independence (Williams and Wood 1988). Instead, research has documented the negative impact that chronic illness has on the psychological well-being of older adults and their families and has focused on older adults' dependence on informal and formal support (e.g., Bazargan and Hamm-Baugh 1995; Beckham, Keefe, Caldwell, and Roodman 1991; Boaz and Muller 1992; Edelman and Hughes 1990; Horowitz 1985; Husaini and Moore 1990; Murrell, Himmelfarb, and Wright 1983; Noelker and Bass 1989; Pearlin, Mullen, Semple, and Skaff 1990; Revenson and Felton 1989; Stone, Cafferata, and Sangl 1987). In this research we examine the behavioral ways that individuals with musculoskeletal disorders adjust to their condition. We are particularly interested in how people's ways of adaptation relate to different domains of activity and how the combination of adaptations and domains of activity are associated with people's perceptions of their independence and dependence.
Previous studies have found that being dependent on others is one of the greatest fears of older adults and that maintaining independence is a goal that has been rated by adults as integral to their quality of life (M. M. Baltes 1996; Clark 1991; Mack, Salmoni, Viverais-Dressler, Porter, and Garg 1997; National Advisory Council on Aging 1992). Generally speaking, dependence is depicted as being associated with practical helplessness, a state of need, incompetence, and functional incapacity (Allen, Mor, Raveis, and Houts 1993; M. M. Baltes 1996; Bond 1976; Braden 1990, Braden 1991; Pratt, Jones, Shin, and Walker 1989; Solem 1976; Vetter, Lewis, and Llewellyn 1992). Discussions of independence typically emphasize personal characteristics such as self-regulation, control, and the ability or opportunity to make choices about important aspects of one's life (Cott and Gignac 1999; Kaufman 1994; Rubinstein, Kilbride, and Nagy 1992; Wahl 1991). The importance of independence is also reflected in health care policy and rehabilitation practice in many North American and European countries, in which autonomy and individualism remain the guiding principles in bioethical theory (Clark 1991; Kaufman 1994; Marshall 1992; Thomasma 1984; Williams 1991).
Despite the value placed on remaining independent by many older adults and health care professionals, we know relatively little about the factors associated with older adults' perceptions of their independence and dependence. On the basis of the research discussed above, we would expect that being dependent would elicit negative feelings, such as a difficulty tolerating or accepting one's condition, perceptions of helplessness, and appraisals that one was not managing or coping well. However, individuals may "impose" a degree of dependency on themselves to prevent or avoid future pain and disability or to leave themselves with the time and energy to focus on other tasks (Gignac and Cott 1998). M. M. Baltes 1996 has described this as "self-regulated dependency" and argued that it may be adaptive and promote successful aging. If individuals retain control and make decisions about the amount of assistance they wish to receive, they may not view their dependence negatively or as reflecting a sense of helplessness or reduced coping efficacy.
In the present study, we focus on differences in perceptions of independence and dependence that relate to five domains of activity—personal care, in-home mobility, community mobility, household activities, and valued activities such as hobbies and leisure pursuits—as well as on the behavioral efforts that adults with chronic illness and disability make to adapt to their condition. As a means of classifying the adaptations made by older adults, we apply Baltes and Baltes 1990 research on selective optimization with compensation. They describe three adaptational processes: selection, optimization, and compensation. Selection processes are invoked in response to losses in functioning or capacity. They include avoiding activities or reducing or restricting one's activities, as well as transforming one's goals. Optimization activities encompass the efforts that people make to augment or enrich their reserves to enable them to continue functioning. Examples include practice, training, and exercise to overcome behavioral decline. Finally, compensation efforts are responses to losses in capacity and include psychological processes or behavioral efforts (e.g., the use of assistive devices) to improve functioning (P. B. Baltes 1997; Baltes and Baltes 1990; M. M. Baltes and Carstensen 1996).
We discuss reliance on others for help as a fourth way that individuals may adapt to their disability. However, the receipt of help can be viewed as a form of selection in that it generally indicates that individuals have given up or reduced their involvement in a particular activity. Help performing activities can also be conceived of as a measure of dependence. For the purposes of this research, we propose to discuss reliance on others for help with activities as a distinct form of adaptation, separate from selection, optimization, and compensation processes, as well as from older adults' perceptions of their dependence. We believe that it is important to differentiate situations in which people give up or restrict activities without receiving help from others from situations in which others intervene to help. For example, by separating selection and receiving help, we can examine whether receiving help is associated with perceptions of dependence, helplessness, negative feelings, and lower coping efficacy or whether it can have positive and adaptive features in some domains of activity.
We hypothesize that people will rely on a different pattern of adaptation in each of the five domains. For example, within the domain of personal care, which includes activities such as bathing, dressing, and eating, we expect that people will devote considerable adaptational efforts to compensating for disability with these tasks rather than forgoing or restricting their activities. This is because personal care and in-home mobility are generally thought of as necessary to daily functioning among community-dwelling adults and because the private nature of many personal care tasks makes it unlikely that people will want to receive help from others unless it is absolutely necessary. Moreover, the nature of many mobility tasks are such that it is often not possible or practical for people to receive assistance with them. Hence, people are likely to make efforts to compensate for losses in these areas (e.g., use assistive devices; Gignac and Cott 1998). They may also devote considerable adaptational efforts toward optimizing their performance in this domain. For example, research on exercise behaviors among individuals with musculoskeletal disorders indicates that exercise can significantly reduce pain and increase functioning (Dekker, Mulder, Bijlsman, and Oostendorp 1993). Valued activities represent another domain in which assistance is often not practical. As a result, people with chronic illnesses and disability may be most likely to give up or limit their participation in these tasks. Finally, for household tasks we expect a wide range of behavioral adaptations. People may limit or give up certain household activities (e.g., heavy housework), they may compensate for problems (e.g., use gadgets for cooking and cleaning), and try to optimize their performance (e.g., plan to make large portions of food and freeze leftovers for later use to save time and energy). People may also rely on others for assistance with tasks (e.g., spouses, paid cleaning help).
We expect that older adults' reports of their independence being affected by their condition and their perceptions of dependence as a result of their disability will, in general, be associated with perceptions of helplessness, emotional difficulty tolerating or getting used to their condition, and a perception that one is not coping successfully. However, we also expect variations in these perceptions that relate to both the type of adaptations used and the domain of activity examined. For example, using the previous illustration, we would expect that help from others for household tasks would be perceived of as dependence but would not necessarily be associated with helplessness, negative feelings, or poor coping in the same way that receiving help with personal care tasks might be. For many older adults, receiving help for personal care tasks signals an important loss in their identity as an independent, autonomous individual (Cott and Gignac 1999; Kaufman 1994) and it is therefore hypothesized to be associated with a loss of control, heightened emotional reactivity, and perceptions of poor coping. At the same time, in other domains such as household activities, individuals may compensate for their disability by making trade-offs in energy and resources and therefore may accept a greater degree of dependence to free up time and energy to pursue other activities independently (M. M. Baltes 1996; Gignac and Cott 1998).
Subjective perceptions of independence may also vary according to the adaptations used across domains. For example, individuals with chronic illness and disability who rely relatively little on the help of others can still report substantial losses to their independence (Gignac and Cott 1998). They may give up established ways of performing activities, and forgo numerous activities, plans, and goals. We expect that, within some domains of activity, modifications to the performance of activities or even giving up activities will be associated with perceptions that one's independence has been affected as well as with perceptions of helplessness, of not coping well, and emotional difficulty tolerating one's condition. In other cases, however, people may report that the adaptations they use to manage their condition allow them to successfully cope and do not adversely impact their independence.
In sum, we have several aims in the present study. First, we identify the behavioral efforts that individuals with a chronic physical illness and disability make to manage their condition. We then examine the pattern of adaptations used by respondents across five domains of activity, including personal care, in-home mobility, household activities, community mobility, and valued activities. We expect differences in the uses of behavioral adaptation that relate to the various domains of activity. We also explore whether differences in domain-specific ways of adaptation are related to older adults' perceptions of their independence and dependence. More specifically, we examine whether the meanings of independence and dependence vary when adults with chronic illness and disability use different ways of adaptation across the domains of activity. To do this, we examine the pattern of correlations that emerges among people's perceptions of their independence, dependence, helplessness, emotional reactivity, and coping efficacy.
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Methods |
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Procedure
Participants were interviewed in their homes using a close-ended, structured questionnaire. On average, interviews lasted 90 min. Items on the questionnaire were a mixture of standardized scales and items specifically developed for this study. The measures are described below. The questionnaire was pilot tested on 8 elderly individuals. As a result, the interview was shortened and minor changes to the wording of some items were made to facilitate their use. The interviews were conducted by nine trained interviewers, and informed, written consent was obtained from all participants.
Measures
Demographics.
Information on respondents' gender, age, marital status, living arrangements, education, income, and employment status was collected.
Impairment.
All participants were asked (a) whether they had OA and/or OP and (b) the number of years that they had been diagnosed with their condition(s). Participants also were asked to rate how much pain they experienced during the previous week. Responses were scored on a 4-point scale from 1 (none) to 4 (severe).
Disability.
Disability was measured by asking respondents about the amount of difficulty they had with 30 activities. When answering, respondents were asked to think about carrying out the activity "without any help from another person or from a special gadget or piece of equipment." The activities were largely drawn from commonly used, reliable, and well-validated, self-report instruments of functional disability, including the Stanford Arthritis Center Health Assessment Questionnaire (HAQ) and the Multidimensional Functional Assessment Questionnaire (OARS) (Center for the Study of Aging and Human Development, Duke University 1978; Fries, Spitz, Kraines, and Holman 1980). We supplemented these activities with additional items, particularly around valued or discretionary activities. The items were divided into five domains: (a) personal care, including dressing/undressing, taking care of one's appearance, eating, bathing, cutting toenails, and toileting; (b) in-home mobility, such as standing up from an armless chair, getting in and out of bed, standing for long periods, sitting for long periods, walking inside one's home, and climbing stairs; (c) community mobility, including getting around the community, getting in and out of a car, and using other kinds of transportation; (d) household activities, such as meal preparation, light housework, heavy housework, yardwork, and errands; and (e) valued activities, such as preparing meals for guests, hobbies (up to two), socializing, travelling for pleasure, outside activities such as religious worship and eating out, physical activities (up to three), and other leisure activities like watching TV and listening to music. Items were scored similarly to the HAQ, with 0 = no difficulty, 1 = some difficulty, 2 = a lot of difficulty, and 3 = unable to do.
To assess participants' degree of disability, we created four disability groups. This was done by averaging the disability scores within each domain of activity. However, activities in some domains were not always performed by the respondent (e.g., cooking). To avoid losing respondents in the analyses due to missing data, we retained respondents who were missing a single activity within the community domain and up to two activities within the household and valued activities domains. The means and standard deviations for each of the domains were as follows: personal care, M = 2.52, SD = 2.08; in-home mobility, M = 5.28, SD = 3.09; community mobility, M = 2.35, SD = 1.96; household activities, M = 0.95, SD = 0.63; and valued activities, M = 0.82, SD = 0.66.
Individuals were classified as having severe disability if one or both of their personal care and in-home mobility scores was above the mean and if they were above the mean on all other domains of activity. Individuals with moderate disability had scores near the mean on both personal care and in-home mobility and scores above the mean on at least household activities or community mobility. Respondents with mild disability had scores below the mean on personal care and in-home mobility and scores near the mean on most other domains of disability. Finally, individuals with scores of 0 or who were below the mean on all the domains of activity were classified as having no disability on a chronic basis.
Behavioral efforts to manage disability.
For all of the 30 activities that respondents indicated at least some difficulty performing, two additional questions were asked, "Have you changed or modified the way that you do this activity (i.e., do you do it in a different way)," and "Do you need assistance from another person or do you need a special gadget or a piece of equipment in order to do this activity?" Responses were in a yes/no format. Respondents answering "Yes" were asked for detail regarding the nature of the modification or the help they received. The questions were open-ended and provided data on the kinds of behavioral efforts that participants made to adapt to their condition. All responses were content analyzed. Details of this coding are described below.
Impact on independence and feelings of dependence.
Prior to answering questions about their level of disability, respondents were asked, "To what extent would you say that your (OA/OP) has affected your independence?" and "To what extent do you feel dependent as a result of your (OA/OP)?" Responses were on a scale from not at all (1) to a great deal (5).
Helplessness.
A 5-item Arthritis Helplessness Scale developed by DeVellis and Callahan 1993 measured participants' perceptions of helplessness in managing their arthritis. The scale is a shortened version of the Arthritis Helplessness Index (AHI), (Nicassio, Wallston, Callahan, Herbert, and Pincus 1985) with similar predictive properties and an acceptable reliability (DeVellis and Callahan 1993). Items were scored on a 5-point Likert-type scale, ranging from strongly disagree (1) to strongly agree (5). Total scores range from 5 to 25 with higher scores indicating greater helplessness. Reliability for the scale in this sample was .64.
Coping efficacy.
Three items measuring coping-efficacy were developed for this study as a measure of respondents' confidence in their current ability to manage or cope with various aspects of their condition. Previous research suggests that people make ongoing appraisals of their efficacy in coping with chronic stressors and that these appraisals are related to psychological well-being (Aldwin and Revenson 1987; Gignac and Gottlieb 1997; Gignac and Gottlieb 1996; Zautra and Wrabetz 1991). The items were, "I am successfully coping with the pain of my condition," "I am successfully coping with the day-to-day problems that living with my condition creates," and "I am successfully coping with the emotional aspects of my condition." Items were scored on a 5-point Likert-type scale, ranging from strongly agree (1) to strongly disagree (5). Because the items were highly correlated with one another we combined them into a scale (rs ranged from .53 to .58, p < .001). Cronbach's alpha for the scale was .79.
Emotional reactivity.
We created seven items to gauge respondent's affective reactions to their condition. As noted earlier, research suggests that being dependent on others can arouse negative emotions in older adults. Therefore, we expected that individuals who perceived that they were dependent on others would be more likely to have difficulty psychologically tolerating the demands of their condition and regulating their emotions. The items were drawn, in part, from the comments generated by individuals with OA and/or OP who discussed living with their condition in focus groups as well as from previous research on the types of appraisals individuals make in response to chronic stressors (Gignac, Cott, and Badley 1999; Gignac and Gottlieb 1996). All items were scored on a 5-point Likert-type scale, ranging from strongly agree (1) to strongly disagree (5). Example items include, "I've never gotten used to living with my condition," "I cannot get used to the limitations in my life that my condition creates," and "It's difficult for me to make plans because I'm never sure how I'm going to feel." Scores can range from 7 to 35, with higher scores indicating greater emotional reactivity or difficulty adjusting to or tolerating one's condition. Cronbach's alpha for the measure was .83.
Content Analysis and Coding
The behavioral efforts that respondents reported to manage the 30 activities assessing disability were content analyzed to identify broad categories of efforts (Holsti 1969). Initially, 25 interviews were randomly selected as the basis for the development of the coding scheme. Subsequently, 13 types of behavioral adaptation were identified and are described in more detail in the Results section. They included performing activities less often, giving up activities or avoiding activities, restricting or limiting activities, spending more time on activities, planning activities to avoid problems, using movement to avoid pain/stiffness, using periods of rest to renew energy reserves, substituting one activity or object with another, modifying or changing the way activities are performed, using furniture or equipment for assistance, using gadgets for assistance, using assistive devices, and receiving help from other people. Monique A. M. Gignac and a research associate met to discuss each of the 13 types of behavioral adaptation, generating examples of all categories. Next, they independently coded responses to all of the activities across the entire sample. Using the coding scheme, agreement rates for the 30 activities ranged from .84 to .96. Differences between the coders were resolved through discussion.
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Results |
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. These processes are also displayed in Table 2 . Behavioral efforts that were indicative of selection included performing activities less often, giving up or avoiding activities altogether, and restricting or limiting activities. In total, selection efforts comprised nearly 21% of all of the behavioral efforts reported by participants. Among these efforts, respondents were least likely to report giving up activities in their entirety. Instead, they were more likely to report restricting or limiting their participation in an activity in some way. For example, some individuals reported that they prepared less elaborate meals for guests when entertaining. Optimization efforts included behaviors that were aimed at augmenting or enriching people's reserves to enable them to continue functioning. Approximately 30% of the ways of adaptation reported by participants were of this sort. Examples of this way of adapting were spending more time and effort on activities and planning activities to avoid problems. Specifically, some participants noted that they routinely booked aisle seats because the extra leg room allowed them to avoid becoming stiff. Others noted that they organized their errands so that they could minimize the amount of walking involved or that they would spread activities out over a period of days to avoid doing too much. Optimization processes also included using movement, such as exercising or stretching before getting out of a bed or chair, in an effort to avoid pain and stiffness as well as using periods of rest (e.g., "pacing oneself ") to continue functioning.
Over 40% of all the efforts reported were compensation processes. This way of adaptation included substituting one activity for another, such as taking showers instead of tub baths and wearing shoes with velcro instead of laces. However, most of the efforts reported consisted of a wide range of modifications to the performance of an activity. For example, people reported numerous modifications to the way they dressed, groomed themselves, got in and out of cars, and prepared meals. Also common were reports of using furniture or equipment for assistance. Some participants noted that they used counters, towel racks, and tables to provide leverage in getting off the toilet or out of chairs. Others reported being unable to negotiate stairs without the assistance of an elevator or escalator. Less frequent were reports of using gadgets and assistive devices to compensate for disability. Gadgets were most often utilized to help with household chores (e.g., food processors, microwave ovens), although respondents reported using luggage on wheels to help with mobility, and one participant used a portable phone in the home to reduce walking. Assistive devices were most often reported to help with personal care (e.g., bath rails, raised toilet seats). However, some respondents reported using mobility devices such as canes, walkers, and wheelchairs either regularly or on occasion when needed. Others reported using special devices like thick grip utensils when eating.
Receiving help from others as a way to adapt to chronic illness and disability made up just over 8% of all responses. Help was most often reported from a spouse or close family member. However, respondents also reported receiving paid help for tasks like housecleaning and yard maintenance, and in some cases, help from services like Meals on Wheels or home care.
Domain Specificity of Adaptation
In this next section we examine participants' reports of the four ways of adaptation across different domains of activity. As outlined in the introduction, we expected differences in reports of the adaptational processes across personal care, in-home mobility, household activities, community mobility, and valued activities. Table 3 presents the number of reports of selection, optimization, compensation, and receiving help across each of the five domains, as well as the percentage of behavioral efforts by domain. We performed separate chi-square tests for each of the four ways of adaptation to examine whether reports of their use differed across the domains of activity. All four tests yielded significant differences in adaptation by domain (p < .001).
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Optimization efforts were most frequent for in-home mobility activities and valued activities. For in-home mobility, these efforts were reflected in exercise and stretching to aid in mobility and in balancing periods of activity with rest to sustain performance. For valued activities, optimization efforts also included planning in an effort to avoid problems (e.g., booking aisle seats in the theatre). Optimization efforts were reported significantly less frequently for personal care and community mobility, although respondents did report some planning and balancing rest and activity in these domains.
Of all the ways of adapting, efforts to compensate for problems performing activities were reported most frequently. The greatest percentage of compensations were for in-home mobility and personal care activities. They included a wide range of adjustments to behavior as well as the use of furniture, gadgets, and assistive devices. Compensation efforts were reported least in the valued activities domain.
As expected, the greatest percentage of helping efforts was reported for household activities. Somewhat surprisingly however, receipts of help were also fairly common in the personal care domain. A further examination of the data within this domain revealed that help was received primarily for two activities: grooming, which consisted mainly of going to a hairdresser instead of doing one's own hair, and cutting toenails, for which help was received from both informal and formal supports (e.g., podiatrists). Help was reported least often for in-home mobility activities.
Perceptions of Independence and Dependence
We next explored people's perceptions of their independence and dependence in relation to the adaptations they used across the five domains of activity. To begin, Table 4 presents means and standard deviations for the items asking people about the impact their disability had on their independence, their feelings of dependence, and the scale scores for helplessness, emotional reactivity, and coping efficacy. The table also presents the overall intercorrelations among the measures. The data revealed that all the measures were significantly intercorrelated (p < .001). The strongest relationship occurred between the measures assessing lost independence and feelings of dependence (r = .73). More modest relationships existed among the impact on independence and feelings of dependence measures and perceptions of coping efficacy (r = -.40, and r = -.39, respectively). The remaining measures exhibited correlations that ranged from .57 to .70.
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Optimization processes exhibited a different pattern of results. They were associated with greater perceptions of lost independence, feelings of dependence, and helplessness for both personal care and in-home mobility, as well as with heightened emotional reactivity and lower coping efficacy for in-home mobility. However, none of the relationships reached significance for community mobility, household activities, and valued activities.
Finally, the more that respondents reported receipts of help, the greater their perception that their independence had been affected, and the greater their feelings of dependence. This was true for all domains except in-home mobility. Given that receipts of help were rarely reported for in-home mobility and given our adoption of a conservative probability level for significance, this finding is not surprising. In addition, receiving help was associated with perceptions of helplessness and emotional reactivity for personal care. For both in-home mobility and community mobility it was associated with greater helplessness, emotional reactivity, and lower coping efficacy. Receiving help was not significantly associated with helplessness, emotional reactivity, or coping efficacy for household or valued activities.
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Ways of Adaptation
We drew upon Baltes and Baltes 1990 theory of selective optimization with compensation to guide our content analysis of the almost 5,000 ways of adaptation reported by respondents. Previous research on the theory of selective optimization with compensation has examined interventions to increase the cognitive functioning of older adults through guided learning (P. B. Baltes 1997; Baltes and Baltes 1990) and barriers to activating adaptational processes that arise as a result of learned dependence (M. M. Baltes 1996). The present study extends the theoretical application of the Baltes's work by applying it to the adaptational processes that community-dwelling, older adults who have a chronic physical illness with disability use to manage their condition.
The findings suggest that older adults use a wide range of adaptations in response to chronic illness and disability. These included efforts to compensate for disability, efforts to optimize performance to avoid problems or augment reserves, decisions to limit or forgo activities, and utilization of help from others. The results do not portray older adults with disabilities as passive or dependent. Instead, older adults were actively engaged in numerous self-care efforts to manage their condition. Most of the behavioral efforts reported by respondents were compensatory. However, it is noteworthy that a large proportion of participants' efforts were aimed at optimizing performance. As noted above, this suggests that older adults do not simply respond to the current demands of their condition but that they anticipate future problems and initiate behaviors that will overcome or avoid these problems. To date, however, little research has focused on people's attempts to anticipate stressors or the anticipatory coping efforts they make to circumvent or minimize stress. Instead, research has emphasized people's responses to losses and limitations in functioning after they have occurred. Future studies need to address this gap.
Domain Specificity of Adaptation Processes
The present study also highlights variability in the adaptations people use across different domains of activity. For example, for valued activities that represent more discretionary activities, respondents often reported giving up or limiting their participation (i.e., selection) or efforts to optimize their performance. This was in contrast to more necessary activities of daily living, such as personal care, in which compensation processes predominated and reports of selection were few. Both in-home and community mobility were dominated by compensation and optimization processes. The nature of these activities makes receiving help difficult. Not surprisingly, people reported this latter strategy only rarely and most often within community mobility in which others helped meet transportation needs. Finally, adaptational processes were most diverse in the household domain with frequent reports of all four ways of adaptation. These results add to a growing body of literature that has targeted coping and adaptation research toward specific populations who are experiencing specific stressors (Gottlieb and Gignac 1996; Williamson and Schulz 1993). In addition to potentially providing a richer portrait of coping and adaptation, such portrayals may strengthen the prediction of the outcomes of adaptational processes. Future research, however, could benefit not only from analyzing the adaptational processes across different domains of activity but also from exploring whether individuals have preferred ways of adapting to disability and the impact of their preferences on their independence, dependence, and psychological well-being.
Perceptions of Independence and Dependence
The complex interrelations among the adaptation processes and different domains of activity are even more apparent when looking at the patterns of correlations that emerged when independence and dependence were associated with older adults' perceptions of their helplessness, their ability to emotionally adjust to their condition, and their perceptions of their coping efficacy. In the present study, having to give up or limit activities (i.e., selection) and having to make efforts to compensate for disability were associated with having one's independence affected, greater feelings of dependence, greater helplessness, greater emotional difficulty dealing with one's condition, and for compensation, less coping efficacy. This was the case for all domains of activity except valued activities. These results suggest that the use of selection and compensation processes may have a negative psychological impact on older adults with OA and/or OP disability in a variety of domains. This may be because these strategies emphasize to people the degree to which their chronic illness has had an impact on their lives. Activities can either no longer be engaged in or performance must be significantly altered to carry out the activity. As a result, people may perceive that their independence has been compromised and that they are dependent and helpless. They may also have difficulty regulating their emotions and psychologically tolerating their condition, and, in some instances, may perceive that they are not coping successfully.
A more diverse pattern of results was found for optimization processes and receiving help. For example, within the domain of personal care, optimization was related to having independence affected, feeling dependent, and feeling helpless. For in-home mobility, it was associated with these same outcomes, as well as with having difficulty emotionally dealing with one's condition and with less coping efficacy. Yet, in the remaining domains none of the relationships around optimization processes reached significance. Caution must be used in interpreting null effects. However, the findings suggest that future research should examine whether efforts to augment or enrich one's reserves can help people maintain their independence and can offset the negative psychological impact of disability in some domains. As mentioned earlier, this research might be particularly timely given the current lack of attention to coping and adaptation processes that are aimed at circumventing stress before it occurs.
Receipt of help from others also displayed an interesting pattern of results. In two domains, namely household activities and valued activities, help from others was associated with reports of having one's independence affected and with feeling dependent, but it was not significantly associated with perceptions of helplessness, emotional reactivity, or lower coping efficacy, as was often the case in the remaining domains. Given that receiving help was reported relatively infrequently for valued activities, the lack of significant findings may be attributable to a lack of statistical power. However, receiving help was reported more often for household activities than in any other domain. Again, caution must be used in interpreting these results, but they provide some initial support for the notion that relying on others may have adaptive features, as well as negative features, and that the psychological relationship that the adaptational processes exhibit will vary according to specific features of the situation (M. M. Baltes 1996; Gignac and Cott 1998). However, these findings need to be replicated in other research. They would also be enhanced by more direct assessments of what help means to people in different domains of activity and of the conditions under which help might be adaptive for people managing chronic illness and disability.
Study Limitations
Several factors limit the generalizability of the present study's findings and need to be addressed in future research. First, our sample was not random and consisted of mainly women. Moreover, although we gained considerable richness and specificity by focusing on the disability that arises from OA and/or OP, our results need to be replicated and extended to other chronic, disabling conditions and to other populations. Specifically, more research with men, with conditions that are more profoundly disabling, and with a broader range of age groups is needed to address the predictors and outcomes of the adaptation processes as well as the various ways that they may be shaped by situational features.
Our findings are also limited by the use of open-ended, self-report data. It is possible that participants did not recall all of the ways that they were adapting to their condition. Of even greater concern is that some of the adaptational processes may be more amenable to recall than others. For example, the loss that comes from giving up or limiting activities may be very salient to people with chronic illnesses. Hence, they may be more likely to recall these adaptations as compared with efforts to optimize their performance. The latter efforts enable people to continue performing the activity and, as our data reveal, they may not carry the same negative psychological weight. If differences do exist in recalling the adaptational processes, it would result in a systematic underreporting of some processes over others. A related problem is that the number of items assessing the different domains of activity varied and may have introduced bias in terms of the relative proportions of one way of adapting compared with another. For example, although it makes intuitive sense that people would report fewer efforts to receive help for in-home mobility than for household activities, our choice of activities may have contributed to differences in reports of the adaptational processes. Research using a variety of methodologies is needed. One example would be to develop a general checklist of the adaptational processes that would compensate for difficulties in recalling adaptational processes.
Our research would also benefit from additional testing of the psychometric properties of the scales developed for use in this study. Specifically, we developed measures of emotional reactivity and coping efficacy for this research. In the present sample, the measures exhibited good internal consistency. In addition, correlations among the measures and assessments of helplessness, perceived independence, and dependence were in the expected directions, lending convergent validity to them. However, additional work is necessary to assess the reliability and validity of the scales.
Finally, the use of cross-sectional, correlational data does not allow us to draw causal inferences from our data. Consequently, we cannot address the causal relations between the adaptation processes used by our respondents and their perceptions of independence, dependence, helplessness, emotional reactivity, and coping efficacy. Longitudinal research would allow researchers to test the prospective relationships among the adaptation processes and psychological variables. In addition, by gauging domain-specific adaptational processes and measures of well-being over time we might get a better sense of whether the adaptations described enable older adults with chronic physical illnesses and disability to "successfully age" by allowing them to minimize their losses and maximize their gains (Baltes and Baltes 1990; P. B. Baltes 1997).
Having acknowledged some of its limitations, the present study extends the research on older adults with chronic illness and disability by examining the processes whereby older adults attempt to adapt to their condition and by examining how these adaptations relate to adults' perceptions of their independence and dependence. The research reveals that a wide range of adaptations are used by adults to manage their disability and it highlights the importance of framing these adaptations within the context of specific domains of activity. Finally, the study underscores the dynamic interplay that occurs among domains of activity and the adaptational processes people use and how these relate to people's perceptions of their independence and dependence, as well as their feelings of helplessness, their ability to psychologically tolerate their condition, and their perceptions of their efficacy in coping with chronic illness and disability.
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Acknowledgments |
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Received for publication March 16, 1999. Accepted for publication April 7, 2000.
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