Journal of Gerontology: PSYCHOLOGICAL SCIENCES
2000, Vol. 55B, No. 6, P362–P372
Copyright 2000 by The Gerontological Society of America
Adaptation to Chronic Illness and Disability and Its
Relationship to Perceptions of Independence and
Dependence
Monique A. M. Gignac,1,2 Cheryl Cott,1,3 and Elizabeth M. Badley1,2
1The
Arthritis Community Research and Evaluation Unit, The University Health Network, Toronto, Ontario, Canada.
2Department of Public Health Sciences, University of Toronto, Ontario, Canada.
3Department of Physical Therapy, University of Toronto, Ontario, Canada.
This study extends research on living with chronic physical illness and disability by examining how adaptation
processes are associated with different activity domains and how the combination of adaptations and activity domains relate to older adults’ perceptions of their independence and dependence, helplessness, emotional reactivity, and coping efficacy. The study investigated the behavioral efforts that 286 older adults with osteoarthritis
and/or osteoporosis used to adapt to disability arising from their condition. The findings revealed that adults
used a wide range of adaptations, including compensations for loss, optimizing performance, limiting or restricting activities, and gaining help from others. The relative use of each of these adaptations varied across 5 domains
of activity: personal care, in-home mobility, community mobility, household activities, and valued activities.
Moreover, older adults’ perceptions of their independence, dependence, helplessness, emotional reactivity, and
coping efficacy varied depending on the domain of activity examined and the type of adaptation used.
C
HRONIC 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 & 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 & Hamm-Baugh,
1995; Beckham, Keefe, Caldwell, & Roodman, 1991; Boaz
& Muller, 1992; Edelman & Hughes, 1990; Horowitz,
1985; Husaini & Moore, 1990; Murrell, Himmelfarb, &
Wright, 1983; Noelker & Bass, 1989; Pearlin, Mullen, Semple, & Skaff, 1990; Revenson & Felton, 1989; Stone, Cafferata, & 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;
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Clark, 1991; Mack, Salmoni, Viverais-Dressler, Porter, &
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, &
Houts, 1993; M. M. Baltes, 1996; Bond, 1976; Braden,
1990, 1991; Pratt, Jones, Shin, & Walker, 1989; Solem,
1976; Vetter, Lewis, & 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 & Gignac, 1999; Kaufman, 1994; Rubinstein, Kilbride, & 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 & Cott, 1998).
M. M. Baltes (1996) has described this as “self-regulated
dependency” and argued that it may be adaptive and promote
ADAPTATION TO CHRONIC ILLNESS AND DISABILITY
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’s (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 & Baltes, 1990; M. M.
Baltes & 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 assis-
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tance with them. Hence, people are likely to make efforts
to compensate for losses in these areas (e.g., use assistive
devices; Gignac & 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, &
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 & 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 & 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 & 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
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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.
METHODS
Participants
Participants in the study were 286 community-dwelling
seniors, aged 55 years or older who had been diagnosed
with osteoarthritis (OA) and/or osteoporosis (OP). About
two thirds of the respondents resided in a large urban center
located in Ontario, Canada, with the remaining participants
residing in smaller urban or rural communities in the same
province. Potential participants were recruited through
newspaper advertisements in community newspapers as
well as through posters placed in rheumatology offices and
rehabilitation clinics. Individuals were screened over the
telephone to determine whether they were eligible to participate in the study. Eligibility criteria included: (a) a physician diagnosis of OA and/or OP, (b) difficulty with at least
some activities related to personal care, mobility, household
activities, or leisure pursuits and hobbies that was attributable to OA or OP, (c) no comorbid conditions causing disability (e.g., emphysema, stroke), and (d) fluency in English. Of 362 screening questionnaires administered, 286
respondents (79%) were eligible to participate in the study.
Individuals ineligible for the study most often had other
conditions in addition to their OA and/or OP that caused
disability. Because the focus in this research was on musculoskeletal disability and its impact, these individuals were
excluded from the study.
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, & 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
ADAPTATION TO CHRONIC ILLNESS AND DISABILITY
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,
& Pincus, 1985) with similar predictive properties and an
acceptable reliability (DeVellis & 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 &
Revenson, 1987; Gignac & Gottlieb, 1997; 1996; Zautra &
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
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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, & Badley, 1999; Gignac & 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.
RESULTS
Demographics
Table 1 presents demographic characteristics, diagnoses,
mean duration of disease scores, mean pain levels, and de-
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GIGNAC ET AL.
Table 1. Sample Characteristics (n ⫽ 286)
Characteristic
M (SD)
Gender
Female
Male
Age
68.3 (8.0)
Marital status
Married
Widowed
Separated/divorced
Never married
Living alone
Education
⬍Secondary school
Secondary school
Some post secondary school
Post secondary school
Total household income
⬍$20,000
$20,000–$39,999
$40,000–$59,999
⬎$60,000
Employment status
Full time/part time
Leave of absence/short- and long-term disability
Unemployed
Retired
Homemaker
Other
Diagnosis
Osteoarthritis
Osteoporosis
Both
Duration
Osteoarthritis
11.7 (10.7)
Osteoporosis
4.7 (5.2)
Pain/discomfort in last week
2.8 (0.9)
Degree of disability
Severe
Moderate
Mild
None
Table 2. Number and Percentage of Occurrences of Adaptation
Behaviors
Number (%)
245 (85.7)
41 (14.5)
145 (50.7)
70 (24.5)
49 (17.1)
22 (7.7)
119 (41.8)
56 (19.7)
50 (17.5)
68 (23.9)
111 (40.0)
46 (21.9)
74 (35.1)
44 (20.9)
47 (22.3)
39 (13.6)
13 (4.5)
11 (3.8)
196 (68.5)
14 (4.9)
13 (4.5)
158 (55.2)
38 (13.3)
90 (31.5)
71 (24.8)
68 (23.8)
58 (20.3)
89 (31.1)
Note: Percentages will vary according to sample size.
gree of disability scores for the sample. Two hundred fortyfive women and 41 men were interviewed. Respondents’
mean age was 68.3 years (SD ⫽ 8.0). Approximately half
the sample was married. Overall, the sample was relatively
well educated, retired, and middle class. Most participants
reported OA (55%) or a combination of both OA and OP
(32%). There was a great deal of variation in the duration of
the two conditions, with the mean number of years of OA
reported as 11.7 years (SD ⫽ 10.7) and of OP as 4.7 years
(SD ⫽ 5.2). On average, participants reported mild or moderate pain in the previous week. There was a range of disability levels in the sample with approximately half the respondents reporting moderate or severe disability across the
five domains of activity and the other half reporting mild or
no chronic disability.
Ways of Adaptation
Table 2 presents a typology of 13 different behavioral efforts that emerged from the content analysis of the ways re-
Reported
Occurrences
Adaptation Type
Selection
Perform activity less often
Give up activity or avoid
Restrict or limit activity
Total
Optimization
Spend more time on activity
Plan activities to avoid problems
Use movement to avoid pain/stiffness
Use periods of rest
Total
Compensation
Substitute one activity or object with another
Modify or change the way activities are performed
Use furniture/equipment for assistance
Use gadgets for assistance
Use assistive devices
Total
Receive help
Help from other people
Total
Number
%
404
121
502
1027
8.2
2.5
10.2
20.9
489
631
214
111
1445
9.9
12.8
4.3
2.3
29.3
225
866
524
198
235
2048
4.6
17.6
10.6
4.0
4.8
41.6
406
4926
8.2
100.0
Note: Mean number of behaviors per respondent ⫽ 17.2.
spondents managed their disability. The table also displays
the number of instances reported of each type of adaptation
and its relative use compared with all other types of adaptation. A total of 4,926 behavioral efforts were reported by
participants to manage their chronic illness and disability
with a mean of 17.2 efforts per respondent (SD ⫽ 11.8; Mdn ⫽
16.0). Only 10 respondents (4%) reported no efforts to modify their behaviors in response to difficulties with the 30 activities.
An examination of participants’ efforts suggested that
they could be organized to reflect the adaptational processes
described by Baltes and Baltes (1990). 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 orga-
ADAPTATION TO CHRONIC ILLNESS AND DISABILITY
nized 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).
As expected, respondents reported giving up or limiting
their activities (i.e., selection) most often within the domain
of valued activities (41% of selection efforts) and least often
in the personal care domain (8% of selection efforts). For
personal care activities, selection generally took the form of
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performing an activity less often rather than giving it up entirely. However, some respondents did report that they
avoided certain kinds of clothing (e.g., clothing with buttons).
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.
We next looked at the correlations among the four adaptational processes and respondents perceptions of their lost
independence and feelings of dependence across the five
domains of activity. In addition, we correlated the domainspecific adaptations with the measures of helplessness,
emotional reactivity, and coping efficacy. Given the number
of correlations calculated and the exploratory nature of the
analyses, we adopted a conservative probability level of
.001 as significant. Table 5 presents the results.
Although there were some similarities in the correlations
among the psychological variables for each domain of ac-
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Table 3. Number and Percentage of Occurrences by Domain for the Four Adaptation Types
Personal Care
Adaptation Type
Selection
Optimization
Compensation
Receive help
Total
In-Home Mobility
Community Mobility
Household Activities
Valued Activities
No. (%)
No. (%)
No. (%)
No. (%)
No. (%)
80 (8.7)
152 (16.5)
569 (61.7)
122 (13.2)
923
188 (14.4)
443 (34.0)
662 (50.7)
12 (0.9)
1305
96 (16.8)
182 (31.9)
266 (46.7)
26 (4.6)
570
242 (24.8)
282 (28.9)
289 (29.6)
162 (16.6)
975
421 (36.5)
386 (33.5)
262 (22.7)
84 (7.3)
1153
Note: Separate chi-square tests for selection, optimization, compensation, and receive help revealed significant differences in the reported use of each of the ways
of adaptation, across the domains of activity ( p ⬍ .001 for all tests).
tivity, the pattern of correlations often varied by the type of
adaptation used. In general, selection and compensation
processes were associated with perceptions of a loss of independence, greater feelings of dependence, helplessness,
and, in some cases, lower coping efficacy across most domains of activity. The exception was with valued activities.
Within this domain, giving up or limiting activities was only
significantly related to the perception that one’s independence had been affected. Compensation processes were not
significantly associated with any of the outcomes within
this domain.
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 inhome 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 sig-
Table 4. Means, Standard Deviations, and Correlations Among
Variables: Impact on Independence, Feel Dependent,
Helplessness, Emotional Reactivity, and Coping Efficacy
1. Independence
2. Dependence
3. Helplessness
4. Emotional reactivity
5. Coping efficacy
M
SD
1
2
3
4
5
—
0.73
0.59
0.61
⫺0.40
2.6
(1.3)
—
0.58
0.57
⫺0.39
2.2
(1.2)
—
0.70
⫺0.58
12.8
(3.2)
—
⫺0.62
18.0
(5.3)
—
11.4
(2.0)
Notes: Means (and standard deviations) are shown in the diagonal. All correlations are significant at p ⬍ .001.
nificantly associated with helplessness, emotional reactivity, or coping efficacy for household or valued activities.
DISCUSSION
This study examined the perceptions of independence
and dependence held by 286 older adults with chronic illness and disability. It examined the behavioral efforts that
these adults used to manage their disability and how these
adaptations differed across several domains of activity.
Overall, the data revealed that when people perceived that
their independence had been affected and/or when they felt
dependent, they were more likely to report feeling helpless,
believe that they were not coping successfully, and report
that they were having difficulty tolerating and adjusting to
the demands of their condition. However, these findings
varied depending on the type of adaptations used and the
domain of activity examined.
Ways of Adaptation
We drew upon Baltes and Baltes’s (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 & 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
ADAPTATION TO CHRONIC ILLNESS AND DISABILITY
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Table 5. Correlations of Domain-Specific Adaptations With Impact on Independence, Feel Dependent, Helplessness, Emotional Reactivity,
and Coping Efficacy
Outcomes
Domain
Selection
Personal care
In-home mobility
Community mobility
Household activities
Valued activities
Optimization
Personal care
In-home mobility
Community mobility
Household activities
Valued activities
Compensation
Personal care
In-home mobility
Community mobility
Household activities
Valued activities
Receives help
Personal care
In-home mobility
Community mobility
Household activities
Valued activities
Impact on Independence
Feel Dependent
Helplessness
Emotional Reactivity
Coping Efficacy
0.35
0.26
0.33
0.22
0.25
0.31
0.20
0.30
0.21
0.27
0.26
0.16
0.31
0.23
0.30
0.22
0.27
0.27
0.22
0.28
0.20
0.28
0.22
⫺0.20
0.43
0.46
0.37
0.32
0.38
0.40
0.34
0.24
0.35
0.37
0.24
0.26
0.34
0.36
0.24
0.31
⫺0.26
⫺0.29
0.35
0.39
0.25
0.22
0.24
0.32
0.29
0.28
0.32
0.21
0.26
0.26
0.25
0.24
⫺0.23
⫺0.25
⫺0.23
Note: All correlations are significant at p ⬍ .001.
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.
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.
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 & Gignac, 1996; Williamson & Schulz, 1993). In addition
to potentially providing a richer portrait of coping and adaptation, such portrayals may strengthen the prediction of the
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 indepen-
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GIGNAC ET AL.
dence 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 &
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 &
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
ADAPTATION TO CHRONIC ILLNESS AND DISABILITY
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.
Acknowledgments
This research was supported by an Ontario Ministry of Health, Health
System-Linked grant to The Arthritis Community Research and Evaluation
Unit, and by Grant 410970184 from the Social Sciences and Humanities
Research Council of Canada. We thank Christine Dixon for her work in
managing the project and for her coding efforts and Debbie Sutton for her
data management and analysis work.
Address correspondence to 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: [email protected]
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Received March 16, 1999
Accepted April 7, 2000
Decision Editor: Toni C. Antonucci, PhD