The Impact of Social Support on Perceived Control Among Older Adults: Building Blocks of Empowerment

Introduction

Americans are aging at an unprecedented rate, and, by the year 2030, more Americans will be over age 65 than at any other point in history (He, Segupta, Velkoff & DeBarros, 2005). "Rural communities generally have a higher proportion of older persons in their total population than urban areas" (Gerrior & Crocoll, 2008, pg. 1), making them an important focus of research and practice. Further migration of aging Baby Boomers will represent a rural population shift such that by 2020, if migration patterns continue, the number of rural adults age 55 - 75 will increase by 30% (Cromartie & Nelson, 2009).

While many rural, older adults today elect to age-in-place, this does not mean they have what they require as their physical and social needs change (ERS, 2005). Older adults' quality of life is affected by normative and non-normative aging, commonly including six dimensions of daily life (functional ability, health, resources, and support from family, friends, community). Previous research has indicated that quality of life for older adults is impacted by health, functional status, and well-being (Keller, 2004; Drewnowski & Evans, 2001). Support, defined as emotional, instrumental, informational, and appraisal, has demonstrated positive health outcomes (Langford, Bowsher, Maloney & Lillis, 2008).

While much focus is on a medical model of individual physical experiences of getting older, aging is more complex, involving social, relational, and contextual processes. We assert that the complex processes of aging can threaten quality of life, perceived sense of control, and resultant feelings of empowerment. While researchers have acknowledged that empowerment is difficult to define (Page & Czuba, 1999; Rapport, 1984), we demonstrate the connection between perceived sense of control and the six dimensions of elders' daily life, including the role of rural support (Figure 1). Most important, we demonstrate the critical link between social support from friends, family, and community and older adults' perceived sense of control. These results further elucidate the complex path to empowerment.

Figure 1.
Conceptual Model Illustrating Dimensions of Daily Life, Perceived Sense of Control, & Empowerment

Review of Literature

More Americans are living into later life than ever before, presenting new opportunities and challenges for families and communities. The surge of Baby Boomers entering later life, combined with budget constraints, is creating unique challenges (Markle-Reid, Weir, Browne, Roberts, Gafni & Henderson, 2006), especially in rural communities that already face limited or no formal transportation and/or social services. Further, the decline in nursing home utilization and increase in home- and community-based services reveal more elders aging-in-place than ever before, many of whom are doing so in rural communities (Gerrior & Crocoll, 2008).

As they age, older adults commonly cite changes in social contact, emotional support, mental stimulation, belongingness, and physical activity (Heathcote, 2000), vital elements that can impact perceived empowerment. Empowerment generally refers to a myriad of experiences, namely feelings of power, authority, and self worth (Wolff, 1993; Gagnon, Hebert, Dube & Dubois, 2006). Page and Czuba (1999) acknowledge there is "no clear definition of the concept" (pg. 1). The Cornell Empowerment Group defines empowerment as "an intentional ongoing process centered in the local community, involving mutual respect, critical reflection, caring, and group participation, through which people lacking an equal share of valued resources gain greater access to and control over those resources" (as cited in Bergland & Narum, 2007, p. 51). And while Page & Czuba (1999) discuss empowerment as a process characterized by the expansion of and change in power within relationships, others have described empowerment as the control one maintains over life, which includes opportunities to make choices and feel free to use personal resources (Heathcote, 2000; Shapira, Barak, & Gal, 2007).

Rapport (1984) acknowledged that the absence of power is much easier to define than the action needed to facilitate empowerment. Kuypers and Bengston (1973) established the Social Breakdown Syndrome, a model that illustrates how pervasive ageist beliefs about older persons contribute to their decline. This model illustrates barriers to empowerment including benevolence (comparison to children); exclusion (isolation from others due to needs); and authoritarianism (younger persons know better) (Corrigan, 2004). When others believe that older persons are incapable, older adults can internalize such beliefs. When elders are not included in decision-making, for example, this can lead to a poor perception of self, often resulting in the need for additional support. Perceived feelings of ineffectiveness can result in depression, loss of self-worth, and social isolation (Kuypers & Bengston, 1973).

While we acknowledge that empowerment is difficult to define, scholars acknowledge that empowerment can include an individual's perceived sense of control. Page and Czuba (1999) assert that empowerment is a "social process that helps people gain control over their own lives" (pg. 1), implying that empowerment may lead to a sense of perceived control. Conversely, Collins (2001) stated that "a sense of control, enhanced by continuing education, can then lead to improved health and a better quality of life" (pg.2), implying that a perceived sense of control is linked to increased mastery and independence, vital elements of perceived empowerment.

Our hypothesis is twofold: 1) a sense of perceived control is mandatory for the process of empowerment; and 2) social support, beyond health, functional ability, and resources, is a strong predictor of perceived sense of control. Further, we assert that understanding predictors of perceived sense of control informs our understanding of the empowerment process, bringing us closer to facilitating empowerment among older, rural citizens.

Method

Community-dwelling, rural Oklahomans age 65 and older were the population for the study reported here. Using random digit dialing, a sample of 404 rural, older adults were surveyed via phone by an independent survey research center. All survey staff were properly trained professionals who were employed by a comprehensive survey research center. Interviews lasted between 30-60 minutes. All individuals who were surveyed responded only for themselves (i.e., proxies were not used). Oklahoma State University's Institutional Review Board approved the survey. Survey contents included demographics, functional ability assessment, dietary intake; assessment of physical and psychological health, financial resources, feelings about decision-making, and the roles others play in one's life; and perceptions of self and life in general, based on self-report data. The specific constructs and associated variables used for this article are described in Table 1.

Table 1.
Constructs Measured and Associated Variables

Construct	Variables
Functional Ability ADLs (α = .839) IADLs (α = .850)	Do you need assistance with bathing? dressing? eating? Do you need assistance with housework? laundry? transportation? grocery shopping? meal preparation?
Health and Well-being (α = .530)	How would you rate your physical health? Overall, how concerned are you today about your physical health? Do you feel your emotional well-being is good? Do you feel somewhat happy at least each day? How often do you feel nervous?
Financial Resources (α = .590)	Do you have enough money to buy the food you eat? Do you have enough money for the health care you need? Do you have adequate transportation to get where you need to go?
Family Support (α = .294)	How often does your family help you? How often would you say that you have at least two family members that you can count on?
Friend Support (α = .169)	How often do your friends help you? How often would you say that you have at least two friends that you can count on?
Community Support (α = .577)	How often would you say that your community is a supportive and friendly place for you? How often are people in your community helpful to others in need? How often are your health care providers (nurses, doctors) helpful to you when needed?
Perceived Sense of Control (α = .093) (dependent variable)	How often do you feel in control of your life? How often do you feel as though others keep you from making decisions about your life? How often do you feel that others have more control over your life than you do? How often would you say that luck plays a big role in your life? How often would you say that you are persistent and can do what may seem impossible to others?

In order to determine predictors of perceived sense of control, hierarchical multiple regression was used. Hierarchical multiple regression allowed for the inclusion of multiple independent variables. Introducing them one at a time allows researchers to control for each variable to determine their independent influence on an outcome. The independent variables/constructs were Activities of Daily Living (ADLs); Instrumental Activities of Daily Living (IADLs); resources; health and well-being; friend support; family support; and community support. The dependent variable was the construct, perceived sense of control (see Tables 1 & 2). In step one, ADLs, IADLs, resources, as well as health and well-being were entered. In step two, three dimensions of support were entered: friend support, family support, and community support.

Results

The results of the hierarchical multiple regression were not significant for step 1 (Δ R² = .01, p > .05) but were significant for step 2 (Δ R² = .05, p < .001). This reveals that among this random sample of community-dwelling, older rural citizens, health, functional ability, and resources were not significant predictors of perceived sense of control. Further, the significant results in step 2 indicate that all support variables, including support from friends, family, and community, were significant predictors of an older adult's perceived sense of control. And while support from friends was not a significant predictor as a part of this model, if it were entered into the model by itself (i.e., without family and community support), it would emerge as a significant predictor (p < .05).

Table 2.
Standardized Coefficients Predicting Perceived Sense of Control

	β	Δ R2
Functional Ability, Health and Resources		.01
ADLs	-.05
IADLs	.13d
Health and Well-being	.05
Resources	.09
Support		.05***
Support from Friends	.07c
Support from Family	.11
Support from Community	.14
N = 403, R2 = .06, F (7, 396) = 3.60, p < .01. Reported βs are from final regression model as the R2 was not significant in regression model 1. c β = .13, p < .05 if entered by itself at step 2. d p < .10 * p< .05, ** p < .01, *** p < .00

Discussion

Empowerment has been discussed in nursing, medical, rehabilitation, human resource, and social service literature. It is a widely recognized term with a number of varied definitions. However, a consistent theme to empowerment is the idea of personal control. What has not been elucidated is what specific role personal control plays in the empowerment process. Is empowerment a predictor? Is it an outcome? How does one promote personal control and ultimately the empowerment for others?

We assert that given the multidimensional and multilevel nature of empowerment, it is essential for older adults to perceive a sense of personal control. More specifically, we claim that a poor sense of personal control thwarts sense of empowerment among older adults. And while the linkage between perceived sense of control and empowerment is not in question, the specific predictors of perceived sense of control remain unclear.

Two key study findings are offered. First, it is notable that functional ability as defined by ADLs and IADLs, along with health and well-being, and resources did not in any way predict older rural citizen's perceived sense of control. There is a widely accepted assumption in American culture that a decline in health and functional ability would be related to, if not result in, a decline in perceived sense of control. Yet our data reveal a different story. Our findings demonstrate that neither functional ability (as defined by ADLs and IADLs) nor health and well-being were a significant predictor of perceived sense of control. Therefore, one could conclude that healthier individuals in this sample were no more likely to experience perceived sense of control than their less healthy counterparts. Additionally, those with significant physical and mobility challenges were as likely as their more mobile counterparts to report a perceived sense of personal control. Finally, the construct of resources was not a significant predictor of perceived sense of control indicating that the reported ability to get one's needs met did not predict perceptions of personal control.

The significant findings tell another important part of the story. As we hypothesized, it was social support resources of friends, family, and community that were most likely to predict older adults' perceived sense of control. While our data do not enable us to explain the specific mechanisms that friends, families, and communities employ to create this significance, this is a critical part of understanding the process of empowerment. And while mechanisms likely vary by individual, family, and/or community, the importance of support in relation to elders' perceived sense of control is clear. We assert that this brings us one step closer to a better understanding of the process of empowerment.

There are three key limitations to the study reported here. These are identified so that readers understand our data and guide scholars to consider alternatives in future research. First, only those with the ability to complete a phone survey were included. Second, our survey was self-report. Self-report survey responses can be biased to reflect responses of social desirability. It is impossible to know if participant responses were valid. Finally, by design our measures were based on perception. For example, we were interested in individuals' perceived sense of control and their perceived support from friends, family, and community. These kinds of questions can yield significant variance.

Application

Extension educators are often the most recognizable educational resource in rural communities. The proportion of elders in rural communities will create both unique demands and opportunities for Extension educators to address aging issues. By doing so, elders, family members, and communities have the opportunity to fully participate in and benefit from the empowerment process. This is demonstrated by Collins (2001), who reported that education is central to the formation of independent living skills and personal control. Further, Collins (2001) claimed that, "a sense of control, enhanced by continuing education, can then lead to improved health and a better quality of life" (p. 2). Therefore, Educators have a critical role in the ongoing process of elder engagement and empowerment.

We would be remiss not to acknowledge the significant impact that the current economic conditions and resultant budget cuts are having on rural communities. In a recent study, Kang and Russ (2009) reported that community centers, often a hub of social and other important activities, are critical to rural citizens' well-being. Yet in light of difficult budgetary decisions, many rural centers are cutting services, including elder nutrition programs. As future budget cuts are made, we believe that the local rural community centers risk losing programs and services for elders. Therefore, support from friends, family, and other informal networks are even more important than ever before. Further, with the outmigration of younger generations from rural communities, there are fewer younger citizens to tend to the needs of aging rural citizens.

Acknowledgement

This research was funded by USDA-CSREES RHSE #2007-04890.

References

Bergland, A.,& Narum, I. (2007). Quality of life demands comprehension and further exploration. Journal of Aging and Health, 19 (1),39-61.

Collins, C. (2001). Seniors CAN: Enhancing independence for older adults. Journal of Extension [On-line], 39(6) Article 6IAW4. Available at: http://www.joe.org/joe/2001december/iw4.php

Corrigan, P. W. (2004). Enhancing personal empowerment of people with psychiatric disabilities. American Rehabilitation Autumn, 2004. Retrieved from: http://findarticles.com/p/articles/mi_m0842/is_1_28/ai_n8681407/?tag=content;col1

Cromartie, J., & Nelson, P. (2009). Baby boom migration and its impact on rural America, ERR-79, U.S. Dept. of Agriculture, Economic Research Service.

Czuba, C., Anderson, S. A., Higgins, S. (2006) Evaluation of the people empowering people program within a prison population. Journal of Extension [On-line], 44(4) Article 4RIB4 Available at: http://www.joe.org/joe/2006august/rb4.php

Drewnowski, A., & Evans, W .J. (2001). Nutrition, physical activity and quality of life in older adults: Summary. Journal of Gerontology 56A: 89-94.

Gagnon, M., Hebert, R., Dube, M., & Dubois, M.F. (2006). Development and validation of an instrument measuring individual empowerment in relation to personal health care: The health care empowerment questionnaire. American Journal of Health Promotion, 20, 429 - 442.

Gerrior, S. A., & Crocoll, C. E. (2008). USDA CSREES' role in broadening support for an aging nation. Journal of Extension [On-line], 46(1) Article 1COM2. Available at: http://www.joe.org/joe/2008february/comm2.php

Heathcote, G. (2000). Autonomy, health, and ageing: Transnational perspectives. Health Education Research, 15(1),13-24.

Kang, M., & Russ, R. (2009). Activities that promote wellness for older adults in rural communities. Journal of Extension [On-line], 47(5) Article 5RIB2. Available at: http://www.joe.org/joe/2009october/rb2.php

Keller, H. H. (2004). Nutrition and health-related quality of life in frail older adults. Journal of Nutrition, Health & Aging. 8(4): 245-252.

Kuypers, J. A., & Bengtson, V. L. (1973). Social breakdown and competence: A model of normal aging. Human Development, 16, 181-201.

Langford, C. P. H., Bowsher, J., Maloney, J. P., & Lillis, P. P. (2008). Social support: A conceptual analysis. Journal of Advanced Nursing.25(1): 95-100.

Markle-Reid, M., Weir, R., Browne, G., Roberts, J., Gafni, A., & Henderson, S. (2006). The effectiveness and efficiency of home-based nursing health promotion for older people: A review of the literature. Medical Care Research and Review, 63(5), 531-569.

Page, N., & Czuba, C.E . (1999). Empowerment: What is it? Journal of Extension [On-line], 37(5) Article 5COM1. Available at: http://www.joe.org/joe/1999october/comm1.php

Rapport, J. (1984). Studies in empowerment: Introduction to the issue. Prevention in Human Services, 3, 1-7.

Wolff, T.J . (1993). Coalition building: Is this really empowerment? American Public Health Association Annual Meeting, San Francisco, CA.