Anxiety, Stress, and Coping,
March 2006; 19(1): 15 /31
The relationship between coping, social support,
functional disability and depression in the elderly
E. GREENGLASS, L. FIKSENBAUM, & J. EATON
York University, Toronto, Canada
Abstract
The increase in the number of older people and the functional disability associated with increasing age
have caused concern regarding the consequences of large numbers of elderly people who are limited in
their functional ability. One of the psychological factors that should be related to functional disability
in the elderly is the way they cope with stress. The present study examines the use of proactive coping
in the elderly in relation to their depression and their functional ability. Results of structural equation
modeling showed that proactive coping was negatively associated with functional disability and with
depression. Social support was positively associated with proactive coping and negatively with
depression. Depression was positively associated with functional disability. A significant implication of
the results is the importance of studying the combined relationship of social support and coping to
elderly functioning.
Keywords: Elderly, depression, functional disability, coping, social support
With the rapidly growing number of seniors, there is agreement that functional limitations
and disability are among the most significant challenges to confront health care in the new
millennium (Fried & Guralnik, 1997). Functional ability is defined as the activities and
tasks that people do on a daily basis. Assessment of disability is of increasing interest to
researchers and clinicians alike in the field of aging. In the case of community-living elderly,
one central concern in research is to identify those at greatest risk of losing functional
abilities and, by the same token, those who risk losing the ability to lead an independent life
in their community. If disability is detected early, then it might be possible to develop
interventions that are aimed at stopping or slowing down the disability process, thus
allowing seniors to remain in the community for longer periods of time. Data indicate that
most seniors live in the community and, particularly, at home rather than an institution. In
1991, for example, 92% of all people aged ]/65 years in Canada lived in a private
household compared with only 8% of all seniors residing in an institution, such as homes
for the elderly, or the chronically ill (Statistics Canada, 2004).
As people age, functional ability decreases and many people find they are unable to do the
daily things that they used to take for granted. This may include shopping for groceries and
personal items, bathing, climbing stairs, or taking a bus or train oneself. According to
previous research, demographic factors are related to functional disability, such as advanced
Correspondence: Dr Esther Greenglass, Department of Psychology, York University, Toronto, Ontario, Canada
M3J 1P3. E-mail: [email protected]
ISSN 1061-5806 print/ISSN 1477-2205 online # 2006 Taylor & Francis
DOI: 10.1080/14659890500436430
16
E. Greenglass et al.
age (Hebert, Brayne, & Spiegelhalter, 1997; Rathouz et al., 1998), female gender (Dunlop,
Hughes, & Manheim, 1997; Oman, Reed, & Ferrara, 1999), and chronic diseases including
arthritis, diabetes, heart disease, and hypertension (Boult, Kane, Louis, & McCaffrey,
1994; Langlois et al., 1996). Additional chronic health conditions that become more
prevalent with age include respiratory illness, stomach problems, and vision and hearing
impairments. These conditions also contribute to impairment of functional ability
(Kempen et al., 1999). Research findings on the elderly indicate further that older
individuals report higher levels of depressive symptoms than their younger counterparts
(Mirowsky & Ross, 1992; Newman, 1989). Possible explanations for this include losses
arising from the aging process, including social losses, and life transitions.
Low levels of psychological resources are associated with functional decline (Ormel et al.,
1997) and depression (Greenglass, 2002). For example, in their study of instrumental
behaviors of daily living community-dwelling seniors, Kempen et al. (1999) concluded that
older individuals with fewer psychological resources are particularly at risk for developing
disability. Resources may include coping strategies and social support. Individuals vary
widely in their coping strategies. While some are unable to cope with the slightest problem,
others appear to handle even the most difficult situations with competence and grace. For
most, their coping responses are somewhere between these two extremes.
Coping has been defined by some as a multidimensional process involving cognitive,
behavioral, and emotional efforts to deal with stressful events that create demands on the
individual (Carver & Scheier, 1994; Folkman, 1984; Folkman & Lazarus, 1980, 1985;
Parker, Endler, & Bagby, 1993). In the past, the dominant conceptual model in research
focused on coping effectiveness as manifest in the reduction of distress. However, coping
may have other functions. For example, proactive coping is conceptualized more broadly as
an approach to life in which an individual’s efforts are directed towards goal management
where demands and different situations are seen more as challenges rather than stressors
(Greenglass, 2002; Schwarzer & Taubert, 2002). The proactive perspective may best be
described by Zea & Tyler (1996) as ‘‘a general style or orientation that pervades the way an
individual approaches life activities facilitating positive outcomes’’ (p. 331). To the extent
that individuals offset, eliminate, reduce or modify ‘‘stressful events,’’ proactive coping can
improve one’s quality of life. The skills that characterize this behavior may include
planning, goal setting, organization, and mental simulation (Aspinwall & Taylor, 1997).
The Proactive Coping Inventory (PCI) was constructed to assess different dimensions of
a proactive approach to coping and consists of seven subscales: proactive coping, preventive
coping, reflective coping, strategic planning, instrumental support seeking, emotional
support seeking, and avoidance coping (Greenglass, Schwarzer, & Taubert, 1999). The
PCI is theoretically based on Schwarzer’s Proactive Coping Theory (Schwarzer, 1999a). In
constructing the PCI, the Proactive Attitude Scale (Schwarzer, 1999b) and the General Self
Efficacy Scale (Schwarzer, 1998; Schwarzer & Jerusalem, 1995) were used as external
criteria to locate items related to proactivity. Taken together, these scales assess relatively
persistent beliefs in one’s own competence to deal with demanding circumstances as well as
beliefs in the rich potential for changes that can be made to improve oneself and/or one’s
environment (Schwarzer, 1999b). For this study, we will focus only on one of the PCI
subscales, namely the Proactive Coping Scale, a 14-item scale that combines autonomous
goal setting with self-regulatory goal attainment cognitions and behavior. By using proactive
coping, the individual strives actively for improvement in one’s life instead of mainly
reacting to an adversity. Proactive coping integrates motivational and intentional aspects
with volitional maintenance processes.
Relationship between coping, social support, functional disability and depression
17
The PCI was developed using data from a sample of 248 Canadian students and then
tested with a 144 Polish-Canadian adult sample (Greenglass, Schwarzer, & Taubert, 1999;
Taubert, 1999). Statistical techniques such as Pearson product-moment correlation, factor
analysis, principal component analysis, and reliability procedures were employed to support
the theoretically based development process and to enhance the quality of scale
construction. For the Proactive Coping Scale, Cronbach alphas of 0.85 and 0.80 were
obtained for the Canadian and Polish-Canadian samples respectively. The scale displays
good item-total correlations and acceptable skewness as an indicator of symmetry around
the mean. A principal component analysis with varimax rotation confirmed its factorial
validity and homogeneity, supporting a one-factor solution (Greenglass, Schwarzer, &
Taubert, 1999). Consistently high internal reliability ratings for the Proactive Coping Scale
have been reported in a variety of samples including Turkish Canadians (A. K. Uskul &
E. Greenglass, 2005), Polish university students (Pasikowski, Sek, Greenglass, & Taubert,
2002), Canadian employed adults (Greenglass, 2006), and rehabilitation hospital patients
(Greenglass, Marques, de Ridder, Behl, & Horton, 2003), ranging from 0.79 to 0.87, with
most having values /0.80, thus providing evidence for the scale’s high internal consistency.
Previous research reports moderately positive correlations between scores on the
proactive coping subscale and self-efficacy (Greenglass, 2002; Greenglass, Schwarzer, &
Taubert, 1999), thus suggesting that self-regulation is one of the dimensions of proactive
coping. Additional data show that Proactive Coping Scale scores are significantly and
positively associated with scores on external scales assessing active coping in the Canadian
and Polish Canadian samples. Moderate to high correlations (from 0.42 to 0.62) were
obtained between proactive coping scores and scores on active coping, preventive coping,
and internal control, a measure of the extent to which the individual takes the initiative in
coping efforts (Greenglass, Schwarzer, & Taubert, 1999). Scores on the proactive subscale
correlate positively and significantly with scales assessing planning, goal setting, and
positive reframing, thus enabling persons to prepare and ward off stress before it occurs
(Greenglass, Schwarzer, & Taubert, 1999).
Research reports significant moderately negative correlations between proactive coping
scores, denial ( /0.31) and self-blame (/0.47) in Canadian university students (Greenglass, Schwarzer, & Taubert, 1999). Proactive coping correlates significantly and negatively
with depression in Canadian university students (/0.49), in Polish-Canadians (/0.41)
(Greenglass, Schwarzer, & Taubert, 1999), and in Polish university students (/0.51)
(Pasikowski et al., 2002). Findings further indicate that proactive coping is significantly
associated with lower burnout and higher professional efficacy in employed Canadian
adults (Greenglass, 2002, 2006), and with lower threat and less loss appraisals in German
teachers (Schwarzer & Taubert, 2002). Taken together, the data suggest that proactive
coping is a self-regulatory coping strategy that is associated with higher levels of well-being,
lower levels of depression, and better psychological functioning.
According to previous research (Greenglass, 2002; Schwarzer & Taubert, 2002), there is
an integral relationship between proactive coping and social support. Resources such as
social support lead to the development of proactive coping (Greenglass, 2002). These ideas
those of parallel Hobfoll et al. (Hobfall, Dunahoo, Ben-Porth, & Monnier, 1994), who
discuss the dynamic relationship between coping and social support acquisition. This
approach acknowledges the importance of resources in others that can be incorporated into
the behavioral and cognitive coping repertoire of the individual. Resources from one’s
network, such as information, practical assistance, and emotional support, can contribute
18
E. Greenglass et al.
positively to the construction of individual coping strategies (Greenglass, 1993). Findings
show that social support, the total number of individuals who offer assistance (including
practical help, advice and/or encouragement), was associated with greater proactive coping
in a sample of rehabilitation hospital inpatients (Greenglass et al., 2003).
These considerations suggest that proactive coping should be associated with less
functional disability in the elderly. It is speculated here that there are two reasons for this
hypothesis: first, the elderly proactive individual is more likely to recognize cues that there is
an increased risk of functional disability with aging, and takes steps to deal with it before it
occurs. Second, a highly proactive elderly person is more likely to see himself/herself as
efficacious and therefore initiate behavior directed toward modifiable factors, such as
nutrition and physical exercise.
Social support is another psychological resource that is associated with better
psychological functioning. According to research, depression and functional disability
should decrease with greater social support. For example, Sarason et al. (Sarason, Levine,
Basham, & Sarason, 1983) found that the greater the number of persons providing social
support, the lower the depression scores in male and female respondents. Social support
has also been associated with better mental health in the elderly and with less depression in
particular (Antonucci & Jackson, 1987). Selection of emotionally meaningful social
relationships may be necessary to elicit the resilience needed for successful adjustment to
the difficulties associated with aging (Carstensen, 1992). A social network and social
support are valuable resources for the elderly. Since social support provides resources that
help individuals perform daily tasks, it should be associated with lower functional disability.
The present study and hypotheses
The present study has two objectives. The first objective is to examine the relative
contributions of physical (i.e., health status) and psychological factors (i.e., coping) in
predicting functional disability in older adults. The second objective is to test a psychosocial
model of functional disability that permitted an examination of the direct and indirect
association of psychosocial variables with functional disability. Specifically, it is expected
that higher levels of proactive coping should be associated with lower functional disability
and with lower depression. In addition, social support is seen as associated with lower
functional disability, lower depression, and greater proactive coping.
Methods
Respondents
Respondents were 224 community-residing older adults attending various community
centers that offered programs for seniors. The age of the respondents ranged from 62 to 98
years, with an average age of 75 (SD 6.88) years. Approximately one-half lived alone
(50.5%) and most were retired (88.3%). They were predominantly female (78.2%). Fortyfive percent were widowed, 39.8% were married, and 15.2% were single, separated,
divorced, or common law. Fifty-five percent were involved in volunteer work, on average
7.30 (SD 6.12) h per week. The respondents were also involved in a variety of hobbies and
general interest classes, such as traveling (51%), cooking (49%), gardening (21%), knitting
(13%), yoga (5%), bowling (1.3%), and cards (23%). Only 14.3% reported less than a high
school education; 52.6% had completed high school; 22.5% had completed community
college or an undergraduate university degree; and 10.5% had a postgraduate degree.
Relationship between coping, social support, functional disability and depression
19
Measures
Functional disability Functional disability was assessed using Krause’s (1998) Functional
Disability Scale. This measure assessed respondents’ difficulties with everyday activities
such as dressing, washing, shopping, and using the telephone. It also included more
strenuous physical activities, such as doing heavy work around the house (shoveling snow,
washing walls), stooping, crouching or kneeling, and lifting or carrying something as heavy
as 11.3 kg (25 lb). The original scale, derived from the work of Liang (1990), contains 14
items. For this study, it was modified slightly by adding an item, ‘‘going to the toilet.’’ For
each item, if respondents indicated they had no difficulty, it was assigned a score of 0. A
score of 1 was assigned to items where respondents indicated they had any difficulty. The
respondent’s functional disability score consisted of the sum of 1’s. Therefore, the
functional disability score consisted of the total number of areas in which the respondent
reported having some difficulty. The alpha coefficient for the functional disability measure
was 0.87.
Proactive coping Coping was assessed using the Proactive Coping subscale of the PCI
(Greenglass, Schwarzer, & Taubert, 1999). The Proactive Coping subscale consists of 14
items and combines autonomous goal setting with self-regulatory goal attainment
cognitions and behavior. Examples of items are, ‘‘I always try to find a way to work around
obstacles; nothing really stops me’’ and ‘‘I turn obstacles into positive experiences’’ (see
Appendix A for the proactive coping items).
Respondents were asked to indicate their degree of agreement with each item, using the
following format: 1 /not at all true, 2 /barely true, 3 /somewhat true, and 4 /completely
true. Respondents’ proactive coping score was the sum of their responses for the 14 items.
The alpha coefficient was 0.84. Studies indicate that the Proactive Coping subscale is a
highly reliable and valid measure (Greenglass, 2002; Greenglass, Schwarzer, & Taubert,
1999; Pasikowski et al., 2002).
Depression Depression was measured using four items from the Brief Symptom Inventory
(BSI; Derogatis, 1993), a self-report inventory of psychopathology and psychological
distress (see Appendix B for the depression items). The original scale has six items;
however, two items were not included in this study. One item, ‘‘Thoughts of ending your
life’’, was dropped due to ethical concerns. The other item, ‘‘Feelings of worthlessness’’,
was omitted because it cross-loaded highly on the Psychotocism factor of the BSI
(Derogatis, 1993). A sample item from the BSI is, ‘‘Feeling no interest in things.’’
Respondents were asked to indicate on a five-point scale (1 ‘‘not at all’’ to 5 ‘‘extremely’’)
how much they had been distressed in the past 7 days by the particular complaint in the
item. Items were averaged for each respondent to yield a depression score. Higher scores
indicated higher intensity of depressive symptoms. The internal reliability was 0.87.
The BSI has been shown to be a reliable and valid measure (Derogatis, 1993). Evidence
for the validity of the BSI as a measure of depression is seen a study by Scocco et al.
(Scocco, Meneghel, Dello-Buono, & De-Leo, 2001), who report that elderly subjects with
death or suicidal ideation manifested depressive symptoms on the BSI. Further validity data
for the BSI is seen in a study by Magni et al. (Magni, Frisoni, Rozzini, & De-Leo, 1996),
who assessed a sample of community-dwelling elderly subjects for pain and discomfort in
16 somatic domains (e.g., hands, arms, shoulders, back, and neck) and for depressive
symptoms using the BSI. They found a positive correlation between number of pains
reported and the BSI depression scale scores.
Physical health status Physical health status was measured by the Survey of Health
Problems, an objective checklist used by Health and Welfare Canada (1981) for use in its
20
E. Greenglass et al.
Canada Health Survey. The checklist consists of 21 physical disorders that are
representative of the most prevalent chronic illnesses among the elderly (e.g., arthritis,
diabetes, heart disease, and hypertension). Respondents were asked to indicate those
conditions that applied to them. The more items endorsed, the more chronic conditions
there were, and the poorer the respondent’s health. Physical health status was the sum of
the chronic conditions that the respondent checked.
Social support Twenty-six items from the Social Support Behaviors Scale (SS-B; Vaux,
Riedel, & Stewart, 1987) were used to measure social support. This scale was designed to
measure the number of people who would offer the respondent support when it was
needed, and includes emotional support, practical assistance, and advice/guidance.
Examples of items are: ‘‘Comforts me when I am upset’’ and ‘‘Helps me out with a
move or a big chore’’. Responses were obtained on a three-point scale, where 1 indicated
‘‘no one would do this,’’ 2, ‘‘one person would do this,’’ and 3, ‘‘more than one person
would do this.’’ A mean score was obtained for each respondent by averaging their
responses over 26 items. The alpha coefficient for the overall measure was 0.97.
Demographic information Respondents were also asked to answer general demographic
questions, such as age, gender, level of education, marital status, and living arrangements,
as well as to indicate their involvement in volunteer work, hobbies, and general interest
classes.
Procedures
Several community centers that offered day programs for seniors were contacted. The
researchers attended classes and asked for volunteers to participate in a study on reactions
to day-to-day events in the elderly. If the volunteers agreed, they were asked to complete a
self-report questionnaire. Upon completion, the respondents were instructed to deposit the
envelope in a sealed box located in the center.
Results
Table I presents means, standard deviations, ranges, and correlations among composite
variables. Social support was positively correlated with proactive coping and was inversely
related to depression and functional disability. Proactive coping correlated negatively with
depression and with functional disability. Depression was positively related to functional
disability and physical health status. Physical health status correlated positively with
functional disability.
Table I. Matrix of variables (means, standard deviations and intercorrelation)
Variable
1.
2.
3.
4.
5.
Social support
Depression
Functional disability
Proactive coping
Physical health$
Mean
SD
Range
1
2
3
4
/
/0.25**
/0.22**
18*
/0.08
/
0.44***
/0.33***
0.33***
/
/0.40***
0.45***
/
/0.01
2.45
0.50
1 /3
1.67
0.90
1 /5
5.13
3.55
0 /15
37.56
8.21
19 /56
Note. *p B/0.05, **p B/0.01, ***p B/0.001. $The higher the score, the more chronic health conditions.
5
6.24
3.56
0 /21
Relationship between coping, social support, functional disability and depression
21
A hierarchical regression was conducted in order to determine the relative contributions
of physical and psychological measures in predicting the functional disability of older
adults. Deletion of missing data in the statistical analyses yielded a final sample of 183
respondents. The first block of variables included age and gender. Physical health was
entered in the second step and proactive coping was entered in the third step. Results
indicated that the demographic variables physical health and coping each contributed
significant increments in explained variance in functional disability among the elderly. In
total, the model explained 45% of the variance in functional disability. The demographic
variables accounted for 17% of the total variance in functional disability, physical health
accounted for 19%, and coping accounted for 10% of the variance.
Examination of the b and t values indicated that functional disability increased
significantly with increasing age and poorer physical health, whereas those who employed
proactive coping strategies reported less functional disability (see Table II). Path analysis,
using structural equation analysis techniques, was performed to test the model presented in
Figure 1. This statistical methodology, using AMOS, takes a hypothesis-testing approach to
the multivariate analysis of a structural model relating constructs (Byrne, 1994). Path
analysis was used instead of testing a latent structure model, since it has been argued that
when the sample size is small, parcels or composite factors are preferable, because fewer
parameters are needed to define the construct (Bagozzi & Edwards, 1998). AMOS
generates a chi-square goodness of fit statistic to test the extent to which a hypothesized
model is consistent with the data. The chi-square statistic is the original fit index
for structural models. A small non-significant chi-square value indicates that the model
fits the data well, and that the model and the data are not significantly different from each
other.
Given the sensitivity of the chi-square statistic to sample size, a number of alternative
absolute fit measures have been proposed. Joreskog & Sorbom (1993) have introduced two
absolute fit indices, the Goodness of Fit Index (GFI), and Adjusted Goodness of Fit Index
(AGFI). For the GFI, values of ]/0.90 indicate a close fit between the model and the data.
The AGFI attempts to adjust the GFI for the degrees of freedom of a model relative to the
number of variables. Usually, a value of at least 0.90 is required to accept the model.
Another widely used index is the Root Mean Square Error of Approximation (RMSEA;
Steiger, 1990). The RMSEA is designed to estimate the lack of fit of a model to the
population covariance matrix. If the approximation is good, the RMSEA should be small.
Browne & Cudek (1993) suggest that a RMSEA value of 5/0.05 indicates a close fit, and
values of 5/0.08 represent reasonable fit. PCLOSE is the p value, provided by AMOS, for
testing the null hypothesis that the RMSEA is B/0.05.
Table II. Predictors of functional disability (n/183)
Independent variables
R2
I. Age
Gender
II. Physical Health Status
III. Proactive Coping
Variables
Age
Gender
Physical Health Status
Proactive Coping
DR2
p
0.17
0.17
B/0.001
0.35
0.45
0.19
0.10
B/0.001
B/0.001
b
0.26
/0.09
0.44
/0.33
t
4.43***
/0.71
7.84***
/5.63***
22
E. Greenglass et al.
Social
Support
Proactive
Coping
Functional
Disability
Depression
Figure 1. Theoretical model relating Proactive Coping, Functional Disability, Social Support, and Depression
Two well-known incremental indices of fit assessment are the Normed Fit Index (NFI;
Bentler & Bonett, 1980) and the Comparative Fit Index (CFI; Bentler, 1990). The NFI
and CFI are both based on a comparison of the hypothesized model against a baseline
model, typically the independence model. Given that the NFI has a tendency to
underestimate fit in small samples (Bearden, Sharma, & Teel, 1982), Bentler (1990)
revised the NFI to take sample size into account, and proposed the CFI. Similar to the GFI
and AGFI, values for the NFI and CFI /0.90 are generally considered acceptable. AMOS
generates b values that provide indices of directional relationships among constructs. While
the path models assessed in structural equation modeling reflect hypotheses about
causation among constructs, the results can be correlational (Everitt & Dunn, 1991).
Causation cannot be assumed in a cross-section study.
In the model presented in Figure 1, social support leads to lower functional disability,
lower depression, and higher proactive coping. Proactive coping leads to lower functional
disability and lower depression. All analyses were conducted using AMOS version 4.0
(Arbuckle & Wothke, 1999). The maximum likelihood method of parameter estimation was
utilized. The analysis was performed on 183 respondents. Cases with missing data were
excluded from analyses.
Social
Support
–0.20**
0.18*
–0.28***
Functional
Disability
Proactive
Coping
Depression
0.35***
Figure 2. Modified model
–0.29***
Relationship between coping, social support, functional disability and depression
23
The independence chi-square [x2 (6, n /182) /91.471, p / 0.000] confirmed the
presence of inter-correlations in the data and, therefore, its suitability for SEM analysis.
However, the x2 goodness of fit statistic (x2 (1) /21.949, p / 0.000) failed to support the
theoretical model.
In an attempt to develop a better fitting model, post hoc modifications were performed.
Specifically, the non-significant path from social support to functional disability was
removed and a path from depression to functional disability was added, as suggested by the
modification index. The modified model yielded a good fit of the data to the model. The x2
goodness of fit statistic for the modified model was x2 (1) /1.855, p/0.173. Other fit
indices (e.g., GFI, CFI, NFI, and RMSEA) were highly satisfactory. Table III displays the
fit indices for the models.
Social support was directly related to proactive coping (positive) (b/0.18) and to
depression (negative) (b / /0.20). Proactive coping was associated with lower depression
(b / /0.29) and lower functional disability (b / /0.28). Depression was positively related
to functional disability ( /0.35). Social support was indirectly related to depression through
proactive coping (/0.18 * b/ /0.29). Social support had an indirect association
with functional disability through proactive coping (b/0.18 * b / /0.28), through
depression (b / /0.20 * b /0.35), and through proactive coping and depression
(b /0.18 * b / /0.29 * b /0.35).
Discussion
The results of the present study support the hypotheses that age and chronic health
conditions predict to higher levels of functional disability. Functional disability increased
significantly with more physical disorders reported by the elderly participants, including
arthritis, diabetes, heart disease, and hypertension, for example. These findings coincide
with other studies that report increasing functional disability with age (Hebert et al., 1997;
Rathouz, et al., 1998) and with an increase in chronic diseases (Boult et al., 1994; Langlois,
al., 1996). Chronic medical morbidity is a relatively strong predictor of different domains of
disability (Kempen et al., 1999).
Contrary to previous findings (Dunlop et al., 1997; Oman et al., 1999), functional
disability for women in this study was not significantly higher than for men. It is possible
that more women than men experience functional disability to a degree that precludes their
active functioning and participation in the community, since women have been reported to
suffer more than men from chronic health illnesses (Verbrugge, 1985). Results of the
present study showed that coping was significantly associated with lower functional
disability in the elderly. This finding parallels results of other studies examining the role
of psychological factors in the prediction of functional disability in the elderly. For example,
in the studies of Mendes de Leon et al. (Mendes de Leon, Seeman, Baker, Richardson, &
Tinetti, 1996) and Rejeski et al. (Rejeski, Miller, Foy, Messier, & Rapp, 1996), higher selfefficacy beliefs predicted lower functional decline in the elderly. Thus, to the extent that
individuals believed they could successfully perform intended behaviors, they were less
Table III. Fit indices for models
Model
Initial model
Modified model
x2
df
p
GFI
AGFI
NFI
CFI
RMSEA
PCLOSE
21.949
1.855
1
1
0.000
0.173
0.946
0.995
0.460
0.949
0.760
0.980
0.755
0.990
0.340
0.069
0.000
0.266
24
E. Greenglass et al.
likely to show functional decline. Given that previous research reports moderately positive
correlations between proactive coping and self-efficacy (Greenglass, 2002; Taubert, 1999),
the present data parallel in part previous findings.
One reason that proactive coping contributed to greater functional independence is that a
proactive individual is more likely to regard performance of daily activities as a challenge
rather than a stressor. Some sample items from the proactive coping subscale are, ‘‘I always
find a way around obstacles, nothing really stops me’’ and ‘‘I turn obstacles into positive
experiences.’’ Thus, a proactive elderly individual is more likely to perceive daily activities as
a challenge to be undertaken in order to achieve independence. In this way, daily activities
are not regarded negatively as threats, rather they are seen as opportunities to employ one’s
skills and abilities in order to achieve independence.
Further data in the present study suggest that social support contributed directly to
proactive coping. To the extent that respondents indicated more individuals were available
to offer support when it was needed, they were more likely to report greater use of proactive
coping strategies. Moreover, proactive individuals can identify and mobilize social
resources, thus increasing the effectiveness of their coping strategies (Greenglass, 2002).
In the present study, social support was measured by the number of people who would offer
the respondent support when it was needed (social support included emotional support,
practical assistance, and advice/guidance). Thus, when elderly individuals indicated that
others were available to provide social support, they were more likely to report greater use of
proactive coping. For example, in the present context, the elderly individual may have
received information from their friends regarding the use of handlebars in the bathtub that
would have facilitated independent bathing.
It was also predicted that social support would lead directly to lower functional disability.
The findings did not support this prediction. However, the results of structural equation
modeling indicated that social support was indirectly related to functional disability through
proactive coping. That is, proactive coping mediated the relationship of social support to
functional disability. Taken together, these results suggest that there is a synergistic action of
social support and coping related to functional disability in the elderly such that coping is
enhanced by more support providers and this, in turn, relates to better physical functioning.
The present data parallel observations by Carstensen (1992) that selection of emotionally
meaningful social relationships may be necessary to elicit the resilience needed for
successful adjustment to the difficulties associated with aging. Present findings also
coincide with previous research examining social support and coping in relation to
psychological functioning in the elderly, where it is suggested that coping in the elderly is
a key adaptive mechanism through which social support operates (Holahan, Moos, &
Bonin, 1997).
Present results indicate that proactive coping was associated with lower depression.
These findings are similar to previously reported results of a negative association between
depression and proactive coping in Canadian and Polish-Canadian university students
(Greenglass, Schwarzer, & Taubert, 1999), in Polish university students (Pasikowski et al.,
2002), and in employed Canadians (Greenglass, 2006). Proactive coping is an active coping
style based on individual initiation, optimism, and self-determination. The proactive coper
takes initiative, is active when faced with stressors, and mobilizes resources (Greenglass,
Schwarzer, & Taubert, 1999). Thus, proactive coping is inconsistent with depression, which
has been characterized by personal deficiency, self-blame, and pessimism (Beck, 1967), as
well as avoidance and self-defeating behavior (Burns, 1999). Given that the study’s design is
cross-sectional, it is also possible that depression led to lower proactive coping. Since
Relationship between coping, social support, functional disability and depression
25
depressed individuals are described as having low self-esteem, self-blame, and ideas of
personal deficiency (Beck, 1967), and as a result, they probably also have low self-efficacy,
they may use proactive coping less as these characteristics are opposite to those associated
with proactive coping. Future research could explore this possibility.
Additional findings suggest that social support led to lower depression, an expected
finding given research supporting this relationship in the elderly (Antonucci & Jackson,
1987). Empirical research has shown that older adults who are embedded in active social
networks tend to enjoy better physical and mental health, including lower incidence of
depression, than those who do not maintain strong ties with others. The association
between depression and social support has been reported as well in longitudinal studies. For
example, Holahan & Moos (1986, 1987) found that family support predicted lower levels of
depression over 1 year, controlling for previous depression. In a study of 400 patients with
chronic cardiac illness, higher levels of social support at baseline were significantly related to
fewer depressive symptoms at 1 and 4 year follow-ups (Holahan, Moos, Holahan, &
Bennan, 1995; Holahan, Moos, & Schaefer, 1996; Holahan et al., 1997). Similarly, findings
from a study with outpatients who had rheumatoid arthritis showed that an extended social
network predicted a decrease in psychological distress after 1 year (Evers, Kraaimaat,
Geenen, & Bijlsma, 1998). Taken together, the existing data strongly suggest the predictive
value of social support in relation to psychological distress, particularly depression.
In the present study, it is argued that social support led to lower levels of depression, an
interpretation that is consistent with findings from longitudinal research. However, it is also
possible that the relationship between the variables is inverted, that is that depressed people
elicit less social support than those who are not depressed. According to Burns (1999),
depressed people have a tendency to behave in self-defeating ways, including avoiding
others. Thus, it is possible that others may be less forthcoming in providing social support
to a person who shuns them. According to this interpretation, lack of receptivity on the part
of the depressed individual may lead to lower social support being offered by others. As
Lewinsohn (1974) suggests, depressed individuals obtain insufficient positive reinforcement from others because they lack social skills necessary to elicit positive interpersonal
responses. Given that the data presented here are cross-sectional, the bi-directional nature
of the relationship between social support and depression does not rule out this possibility.
The relationship between depression and functional disability was originally not
predicted. The prediction of this relationship was added due to results indicating a
modification index in the structural equation model. The association between depression
and functional disability has been reported in other studies (e.g., Prince, Marwood, Blizard,
Rhomas, & Mann, 1997; Turner & Noh, 1988). Some argue that there is an impact of
depression on functional disability partly due to decreasing physical activity and social
interactions of depressed people (Pennix et al., 1999). The predictive relationship of
depression on functional disability was also suggested in a longitudinal study of depressed
and non-depressed community-dwelling seniors (55 /85 years old), where there was a
statistically significant relationship between depression and functional limitations and
disability days 5 months later (Geerlings, Beekman, Deeg, Twisk, & Van Tilbury, 2001).
These data suggest a causal link between depression and functional disability. While the
present data preclude attributing causation to depression, the interpretation put forth here
is consistent with previous longitudinal work demonstrating the predictive role of
depression on functional disability. At the same time, given that the present data are
cross-sectional, it cannot be ruled out that functional disability led to greater depression
(Ormel, 2000). In older populations with a high prevalence of chronic disease, disability has
26
E. Greenglass et al.
been found associated with the onset and persistence of depression (Kennedy, Kelman, &
Thomas, 1990).
The present study has important theoretical and practical implications. The theoretical
basis of this study puts forward an integrative model of social support and coping and
examines its synergistic relationship with functional disability and depression. Findings
showed that proactive coping mediated the relationship of social support to depression and
functional disability. Contrary to the past where investigations have focused on relationships
between either social support or coping, and functional disability or depression, the present
theoretical approach has examined the combined relationship of social support and coping
and its association with outcome variables. In this study, social support was measured by
assessing the number of individuals providing emotional support, practical assistance, and
advice/guidance, and thus it is assumed here the number of individuals providing support
and not the quality of support, plays an important role. From a practical perspective, by
increasing the number of support providers, proactive coping strategies should also
increase. And, with an increase in proactive coping, psychological and physical functioning
in the elderly should be enhanced. To the extent that depression levels are lower, functional
disability should also decrease.
These results also extend and enhance knowledge in the area of coping. In the present
context, proactive coping predicts physical functioning in the elderly. Past research has
demonstrated that proactive coping is associated with improved psychological functioning
on a variety of measures. For example, scores on the Proactive Coping subscale correlated
significantly and negatively with depression in Canadian university students and in PolishCanadian adults (Greenglass, Schwarzer & Taubert, 1999). Additional research reports
significant negative correlations between proactive coping, state anger, depression,
emotional exhaustion, and cynicism, and significant positive correlations between proactive
coping scores, life satisfaction, and perception of fair treatment at work in a sample of 178
employed adults in Canada (Greenglass, 2002). Pasikowski et al. (2002) report that scores
on the Proactive Coping subscale correlate negatively with depression and positively with
reported health, defined as a subjective sense of health in the psychological, social, and
physical domains in Polish university students. Additional results indicate that proactive
coping is significantly associated with lower burnout and higher professional efficacy in a
sample of employed Canadians (Greenglass, 2006). Given that proactive coping has been
shown to be a viable construct in the area of elder functioning, its applicability has been
extended. Moreover, present findings show that proactive coping is associated with lower
levels of depression and functional disability, which are some of the major concerns
associated with aging.
The present research has conceptualized the study of functional disability in the elderly
from a stress and coping perspective and in so doing has enabled us to access a considerable
research base which can be applied to the study and understanding of the elderly and their
functional ability. Findings from this research may be employed to suggest practical
interventions that would provide useful assistance in slowing the decline of functional ability
in the elderly, while at the same time empowering them to take greater control of their own
quality of life. For example, the finding that proactive coping was associated with higher
levels of independence functioning suggests that interventions that instruct communitydwelling elderly on how to cope proactively on a daily basis should be associated with an
increase in functional independence. Further findings from the present study indicate a
significant association between social support and lower depression. Thus, interventions
Relationship between coping, social support, functional disability and depression
27
that assist the elderly to develop and maintain their ties with others could be a way of
helping to alleviate their depression.
The present sample was drawn from community-dwelling elderly, the largest population
of the elderly. At the same time, the sample was comprised of volunteer respondents who
attend community centers and therefore would not likely be severely functionally limited or
depressed. As indicated earlier in this paper, only 8% of seniors reside in an institution, and
they would be more restricted in terms of tasks of daily living than those residing in the
community. While on average respondents’ tasks of daily living were not severely restricted,
at the same time data from the present study indicate that the measure of functional
disability employed here was a valid one, since present findings parallel findings from earlier
research, i.e., functional disability increased with age and chronic health conditions
(Langlois et al., 1996; Rathouz et al., 1998). Depression scores in this sample were
moderate, suggesting that this sample of community-dwelling seniors was not seriously
depressed. At the same time, since present findings regarding depression and its relationship to other variables are similar to those reported previously, e.g., a significant association
between social support and depression (Antonucci & Jackson, 1987), present data indicate
that the measure of depression employed here is a valid one.
One limitation of this study pertains to its methodology, particularly that constructs were
assessed by multiple response questionnaires with paper and pencil. As such, common
method variance may be at issue in this study. Also, it has been suggested that proactive
coping, like other constructs under the rubric of ‘‘positive psychology’’, is correlated
positively with other positive constructs such as optimism, good self-concept, etc. In this
regard, however, it does not differ from negative constructs, more often studied in
psychological research, such as depression, which correlate positively with similar negative
variables, such as pessimism and low self-esteem, for example. Another issue already noted
is that the analyses are based on a cross-sectional design. Hence, it is not possible to draw
inferences regarding causal relations among the variables. Since this study assessed
constructs concomitantly, the causal paths in our model are based on hypothesized
relationships that have been assessed in other research. As indicated above, it is possible
that the effects may occur in the other direction. This is particularly the case when
examining the relationships between social support and depression, depression and
proactive coping, and depression and functional disability. While this study was conducted
with active community-dwelling seniors who enjoy a relatively high degree of functional
independence and who are representative of most seniors, it does not examine seniors who
may be less independent and thus are not able to attend and participate in community
center activities. The present study also does not focus on those seniors who reside in
institutions. Since present findings are based on active community-dwelling elderly, further
study is needed to determine the generalizability of the results to other populations of
seniors. It is also worth noting that since only about 20% of the present sample was men,
the findings reported here might be more applicable to women.
To summarize, this study presented an opportunity to test a synergistic model of social
support and coping and its relationship to elderly functioning. The results showed that
proactive coping was negatively associated with functional disability and with depression.
Social support was positively associated with proactive coping and negatively with
depression. Depression was positively associated with functional disability. Thus, to the
extent that the elderly employ coping techniques based on proactivity, they experience
greater physical and psychological well-being. Second, there is an integral relationship
between social support and coping such that social support is positively related to improved
28
E. Greenglass et al.
coping skills. Moreover, given that the present findings have demonstrated the role of
psychological factors (coping) and physiological factors (health status) in predicting
functional disabilities (regression results), they can be seen as an interesting input to
coping research as well as to research on health in the elderly. A significant implication of
the results is the importance of studying the combined relationship of social support and
coping to elderly functioning.
Acknowledgements
Grateful acknowledgement is due to the Faculty of Arts, York University, Toronto, Ontario,
Canada. Appreciation is expressed to the external referees for their helpful comments
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Relationship between coping, social support, functional disability and depression
31
Appendix A
Proactive Coping Inventory (PCI) (Greenglass, Schwarzer, & Taubert, 1999)
Proactive Coping Subscale
The following statements deal with reactions you may have to various situations. Indicate
how true each of these statements is depending on how you feel about the situation. Do this
by checking the number that best describes your feelings.
Not at Barely Somewhat Completely
all true true
true
true
1. When I have a problem, I usually see myself in a
no-win situation. ( /)
2. When I experience a problem, I take the initiative in
resolving it.
3. After attaining a goal, I look for another, more
challenging one.
4. I like challenges and beating the odds.
5. I am a ‘‘take charge’’ person.
6. I try to let things work out on their own. ( /)
7. I turn obstacles into positive experiences.
8. Despite numerous setbacks, I usually succeed in
getting what I want.
9. I always try to find a way to work around obstacles;
nothing really stops me.
10. If someone tells me I can’t do something, you can be
sure I will do it.
11. I try to pinpoint what I need to succeed.
12. I often see myself failing so I don’t get my hopes up
too high. ( /)
13. I visualize my dreams and try to achieve them.
14. When I apply for a position, I imagine myself filling it.
1
2
3
4
1
2
3
4
1
2
3
4
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
1
2
3
4
1
2
3
4
1
1
2
2
3
3
4
4
1
1
2
2
3
3
4
4
Note. / Reverse items.
Appendix B
Brief Symptom Inventory / Depression (Derogatis, 1993)
On the pages that follow is a list of problems people sometimes have. Please read each one
carefully, and circle the number that best describes how much that problem has bothered
you during the past 7 days including today. Circle only one number for each problem and
do not skip any items.
Not at all A little bit Moderately
1.
2.
3.
4.
Feeling
Feeling
Feeling
Feeling
lonely
blue
no interest in things
hopeless about the future
1
1
1
1
2
2
2
2
3
3
3
3
Quite a bit Extremely
4
4
4
4
5
5
5
5