Ann Longterm Care. 2017. Published online ahead of print December 4, 2017.
Research reported in this interview was supported by the National Institute on Aging of the National Institutes of Health under Award Numbers R01AG030486; R01AG047408; and R01AG044368. The content is solely the responsibility of the researcher and does not necessarily represent the official views of the National Institutes of Health.
Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA
Assisted living facilities (ALFs) provide one option for older individuals requiring assistance with personal care services, health-related services, room and board, or additional supervision as they age. The prevalence of this type of facility has grown in recent years—ALFs contributed to 75% of all new senior housing in 1998.1 Many retired Americans favor the lower costs, home-like surroundings, and social care model of ALFs compared with the traditional medical model of a long-term care facility (LTCF). Based on 2012 data from the National Study of Long-Term Care Providers, approximately 713,300 of older Americans reside in ALFs.2,3
But in addition to providing ALF residents with needed assistance with daily activities of daily living and medical services, addressing older individuals’ social and emotional needs is an essential component of the assisted living (AL) philosophy of care. Transitioning from an independent living situation to an AL setting can often result in a feeling of loss in older adults making this move. Along with declining physical functions, individuals may feel a loss of independence and/or feel isolated, contributing to experiences of loneliness and depression.4
A growing body of research has been investigating ALF residents’ social relationships and how these social ties—both inside and outside of ALFs—may impact their health. Assistant Professor of Medicine Molly M Perkins, PhD, Emory University School of Medicine (Atlanta, GA), is one of the leading researchers in this area of study. Dr Perkins serves as a social gerontologist and medical sociologist with varied interests in social determinants of health and disparities, aging in minority and vulnerable populations, functional wellness, and long-term care. She is currently principal investigator/co-principal investigator on two projects funded by the National Institute on Aging and has received funding as a co-investigator through the Patient-Centered Research Outcome Research Institute, the Veterans Health Administration Office of Rural Health, and the John A Harford Foundation.
For a deeper understanding of this area of study and how the findings can be practically applied to improve daily clinical care, Annals of Long-Term Care: Clinical Care and Aging spoke with Dr Perkins about her comprehensive examinations of social relationships and health, taking a specific look at one of her published articles “Social Relations and Resident Health in Assisted Living: An Application of the Convoy Model” 4 and how those findings can be utilized to improve LTCF residents’ quality of life.
Please discuss the current body of assisted living (AL) research related to the link between residents’ social relationships and health?
There is a growing body of literature that focuses on the link between AL residents’ social relationships and health. This research shows that inadequate social support is an important risk factor for depression as well as increased morbidity and mortality.5 Other studies have shown that residents who develop positive relationships in AL adapt better to life in this congregate care setting and report higher levels of subjective well-being.6,7
Reportedly, a key barrier to residents’ ability to develop or maintain meaningful relationships in AL include stigma associated with decline and disability, especially with regard to cognitive impairment.8-10 Within this often socially competitive group environment, cliques, gossip, and conflict contribute to residents’ social challenges and may pose serious threats to their self-concept and overall sense of well-being.5 In response to these threats, research has shown that residents may engage in protective strategies that can be harmful to health, such as social distancing and social isolation.
Ethnographic research suggests that meaningful relationships are more likely to develop among residents who share similar histories, cultural and socioeconomic backgrounds, and functional abilities.9,11,12 Unfortunately, this research also shows that changes in residents’ health and functional ability can substantially impact residents’ ability to maintain these ties. Fear of decline or of being labeled impaired (ie, by association) is a key barrier.9
Although family ties continue to be of utmost importance to most AL residents, some lack family support and even those who have supportive family ties typically only see their relatives on a weekly basis at best.13 Interaction with friends and other nonfamily members in the wider community also remains important and can be key to AL residents’ ability to make a successful transition to AL life and develop new relationships with other residents.9,14 Unfortunately, interactions with people in the wider community often become less common or end following the move to AL. Possibly related to this finding, some research shows that community ties are negatively associated with residents’ subjective temporal well-being.14
A recent qualitative study fills important gaps in this literature by focusing on the social and intimate relationships of married (n = 26) and unmarried (n = 3) couples in AL and examining how these relationships might shape health outcomes.15 Although this study identified beneficial aspects of couplehood, including a shared history and affection, it also identified a number of potential health risks, particularly for a healthier spouse who might have moved to AL based on his or her partner’s need for this care. Potential pitfalls include feeling the burden of caregiving and having more limited opportunities for social interaction with fellow residents based on a spouse’s needs. Findings indicate that strategies to support couples should focus on addressing both their individual and shared needs.
Within the group setting of AL, interactions with fellow residents are unavoidable. Successfully managing these interactions and developing some meaningful relationships inside AL has important implications for residents’ health and overall quality of life, especially for those who lack ties with significant others outside the facility. Some evidence even shows that relationships residents develop with others inside AL may be more important to their health and overall well-being than preexisting ties with significant others outside AL.7,14 In addition to need for instrumental care, many residents move to AL based on a need for social interaction and companionship.11,16
With the right strategies and supports in place, AL can help fill these voids and provide needed and meaningful social engagement for residents. Understanding and addressing barriers to relationship-development that have been identified can contribute to the ability of long-term care (LTC) professionals to successfully promote these ties.
What is the social convoy model, which you utilized in your article,4 and how does the it fit into the current discussion on this topic?
The convoy model of social relations was first developed and introduced by Kahn and Antonucci17 in 1980 and has been used extensively for the scientific study of the links between social ties, aging, and health. Rooted in lifespan and life course perspectives, the model represents a multidisciplinary approach that has been used by researchers from multiple disciplines, including epidemiology, geriatrics/gerontology, psychology, social work, and sociology. The term “social convoy” refers to the dynamic set of network members that surround an individual over the life course and provide different types of social support and assistance necessary for health and well-being over time. The model takes into account changes and life course transitions (eg, retirement, relocation to an AL facility (ALF) or nursing home, and death of significant others) that occur over time as people age and their impact on health. Some evidence shows that older adults with larger and more diverse social support networks are at lower risk for depression and other adverse health outcomes. Evidence also indicates that older adults who lack close family ties or other types of close ties are particularly vulnerable for poor health outcomes.
Heuristically, the social convoy model is conceptualized based on social network ties individuals perceive as “very close,” “somewhat close,” and “less close.” Although social convoys vary, ties perceived as “very close” typically include more family members. Research, including my team’s own research, shows that not all close ties are beneficial to health and can have a negative influence. Based on the model, personal characteristics (eg, age, education level, race) and situational characteristics (eg, characteristics associated with an individual’s living arrangement) influence the types of relationships individuals have access to and need or desire.
The social convoy model has continued to develop, expand, and become more advanced based on several decades of research, including large epidemiological studies conducted at the national and international level, higher-quality data, and more sophisticated analytic methods.18 New research directions include: a focus on the link between stress and health, including perspectives of both care recipients and care providers, and longitudinal investigations into how relationships change over time and the impact these changes have on health and health behaviors. Recently, the model has been applied to special at-risk populations, including older adults aging with HIV19 and older gay men.20 Research reported here represents the first known research to apply the model to AL.
Based on our research in AL, we have expanded this model to include the interface between residents, their informal caregivers, AL staff, and external care providers (eg, physicians, nurses, physical therapists, hospice workers, etc). We conceptualize this new model that is specific to AL as the “convoy of care” model.21 Our ongoing research, funded by the National Institute on Aging at the National Institutes of Health (NIH/NIA R01AG044368-02; PI Kemp) is using the convoy of care model as a conceptual framework to identify effective ways to develop and maintain collaborative care partnerships among residents and their informal and formal caregivers and promote residents’ ability to age successfully in place in AL. Another of our ongoing studies (NIH/NIA R01AG047408-01A1; PI Perkins) adopts a social determinants of health perspective and is using Antonucci’s hierarchical mapping technique22 to help assess the perceived quality and quantity of social support (and social capital) AL residents possess at end of life.
Please summarize your analysis and main findings from your published article “Social Relations and Resident Health in Assisted Living: An Application of the Convoy Model.”4
This mixed methods study uses data from an NIA/NIH-funded study (NIH/NIA R01AG030486-02; PI Ball) that focused on learning ways to create an AL environment that maximizes residents’ ability to negotiate and manage their social relationships with other residents. Although a primary focus of this study was on residents’ social relationships with fellow residents, we also collected qualitative and quantitative data on residents’ relationships with family members, friends, and AL staff. Data collection included qualitative interviews, surveys, and social network mapping using Antonucci’s (1986) hierarchical mapping technique.22
Analysis reported here adopts the social convoy model as a conceptual and methodological framework and uses mixed methods to examine the importance of co-resident relationships to residents’ subjective well-being relative to other network ties (ie, with family, AL staff, and others outside AL). Data are drawn from face-to-face interviews and social network mapping conducted with 192 AL residents from nine ALFs in Georgia. Facilities ranged in size, ownership, and geographic location and were selected to represent the range of facilities nationally. We used descriptive statistics, ordered logistic regression, and thematic analysis to analyze the data.
Findings from social network mapping showed that having a higher proportion of family ties in one’s network was the single most important predictor of well-being and was a stronger predictor than self-perceived health, a variable repeatedly shown to be a powerful predictor of morbidity and mortality. Results also showed the importance of having some ties with fellow residents and nonfamily members outside AL. Notably, findings showed that having a higher proportion of ties perceived as “very close” was associated with lower well-being; the majority (84%) of residents’ closest ties were with family members. Findings suggest that families play a crucial role in residents’ health and overall well-being but also show that not all close ties, including some ties with family members, are beneficial.
Based on our own previous research and that of others, we speculate that many residents yearn for more emotional and social involvement than busy family members are able to provide and that this perceived lack of support may be a source of stress and depression. Our results indicate that residents’ ability to develop supportive ties inside AL is important to their ability to adapt to AL
life and may be crucial to their health and overall well-being especially as other sources of support outside AL narrow. Almost one-fourth (22%) of residents reported a desire for additional network members and this desire was associated with lower well-being, a finding that also highlights the importance of facilitating residents’ ability to develop new relationships inside AL. Less than one-third (29%) of residents in this study included residents in their social network maps, and few of these residents defined these relationships as close. On average, co-residents represented only 7% of all network members included in residents’ network maps. Those who did include residents in their networks also were statistically more likely to include AL staff.
Based on qualitative data, we found some interesting similarities among residents who included co-residents in their social network maps compared with those who did not. Although residents in both groups sometimes used the word “friend” to describe their relationships with co-residents, overall both groups characterized these relationships in terms of peripheral or weak ties and used language like “acquaintance” and “friends just to say hello.” While these relationships may appear insignificant on the surface, our findings show that these “weak” ties are vitally important to residents’ overall well-being.
Qualitative analysis identified several factors associated with residents’ tendency to avoid getting too close to other residents. These factors included not wanting to become the subject of gossip, avoiding incurring, costly social obligations, ie, from people perceived as “needy,” and protecting oneself from emotional pain (eg, resulting from residents’ death, which is common in AL). Some residents who had supportive relationships with family members indicated that they did not seek relationships with other residents because ties with family members fulfilled all of their needs.
Interestingly, ageism also emerged as a factor that hindered relationship development. A 92-year old male resident, for example, told us that he did not want to associate with “a bunch of old people.” Some residents who did not include residents in their network or did not define their relationships with other residents as particularly close referred to time as a factor. Findings suggest that frequency of contact (eg, eating meals together 3 times a day) and repeated patterns of social interaction over time may help break down some of the barriers to relationship development that we and others have identified.
What were some of your more surprising findings and your speculations related to those findings?
Some of the more surprising findings that came out of this study are based on qualitative data and show the advantage of a mixed methods approach to gain a more comprehensive understanding of residents’ experience. In particular, I find similarities we identified among residents who included co-residents in their social network compared with those who did not include co-residents in their networks among the most interesting. Overall, both groups characterized their relationships with fellow residents as not particularly close and residents in both groups used the term “friend” to describe some of these weak ties. We labeled this theme or phenomenon, “peripheral friends.” Although these weak ties do not seem important on the surface, findings from multivariate analysis indicate that having some ties with co-residents is significantly related to well-being. Results indicate that these weak or peripheral ties are clearly important, especially when support is lacking from other network members perceived as close.
Qualitative findings from this study also support earlier findings9 that showed that residents use a number of defense tactics to avoid perceived risks associated with becoming too close to other residents. We think that residents’ tendency to develop relationships with one or two “peripheral friends” may be an adaptive strategy they use to pass the time in AL and cope with the challenges of group life as well as compensate for support that may be lacking from others outside AL.
Qualitative findings from this study have some interesting parallels with earlier findings regarding the importance of weak ties formed among AL staff. One study23 showed that, in the physically and often socially challenging AL work environment, direct care workers, many of whom are working more than one job and juggling multiple family and work responsibilities, often establish boundaries with coworkers to prevent interpersonal conflict (eg, avoid becoming the subject of gossip) and to escape emotional costs and time-consuming social obligations associated with closer ties. Similar to residents, a common strategy we observe staff use to avert perceived risks and “get by” in AL is to forge just one or two “just-close-enough” or “weak” ties with others who have similar abilities and values (ie, staff members with a similar work ethic and work style).
How can LTC professionals utilize your findings and insights in their daily work when caring for residents?
Findings from our study4 support recent trends in medicine and public health emphasizing the importance of considering social determinants of health in addition to clinical factors when developing care plans, including a push now to incorporate social factors into the medical record and triangulate those data with clinical data to map a more comprehensive care plan for patients.
Results provide a number of insights that LTC professionals can use in their daily work with AL residents. The key is being attentive to social factors that can negatively impact residents’ health and overall well-being, including being aware of the existence of cliques and the stigma associated with impairment and decline. Our work shows that residents experiencing decline may isolate themselves and even shun needed assistive devices to avoid having their perceived deficiencies discovered.9 Therefore, it is important to recognize that residents experiencing decline may be particularly at risk socially and healthwise. Residents with physical or mental impairments, particularly those that affect their ability to communicate, also are especially at risk as are new residents (ie, those who have not had time to build relationships).
Unfortunately, in the often socially competitive environment of AL, we find that a lack of socially valued assets, such as physical attractiveness or a pleasing personality, also can limit residents’ ability to develop relationships with other residents. In cases where residents are not able to develop these ties, our research shows that relationships with AL staff and volunteers who may visit the facility can be meaningful.24
Families also need to be educated about the importance of their continued interaction, especially when residents first move into a facility, is experiencing difficulty connecting with others inside the facility, or is experiencing decline that may threaten their established ties. Residents who lack close family ties or other close ties with nonfamily outside the facility may be in particular need of assistance developing relationships with fellow residents and/or staff and volunteers. When choosing a new facility, we find that achieving a good resident-facility fit (ie, where residents share similar histories and cultural and socioeconomic backgrounds) can also be an important factor in promoting residents’ ability to develop relationships with co-residents.9,11,16
How could LTC professionals evaluate/gauge (formally or informally) how their residents are faring socially?
Research, including ours, show links between residents’ perceived social support and subjective well-being.4,7 Formally, LTC professionals might include brief measures of subjective well-being and/or depression as part of regular care assessments. The measure of subjective well-being used in this study consists of one question that asks, “Overall, how satisfied are you with your life as a whole?” Response options range from very dissatisfied to very satisfied. Residents who exhibit signs of depression or score low on subjective well-being should be assessed further for potential need of treatment. Negative results also might indicate that residents are not faring well socially and can be followed up informally with questions related to the quality of their social relationships. As indicated above, informal strategies LTC professionals can use to evaluate how residents are faring socially include being attuned to barriers to relationships we have identified in this article as well as being observant of residents’ behavior and changes in behavior (eg, signs of social isolation).
Practically speaking, what kinds of interventions/programs/activities could be implemented in or developed for LTC settings to help residents create and maintain a range of network ties? What about in one-on-one contexts with individual residents?
ALFs often gear recreational activities toward lower functioning residents, a strategy that contributes to their stigma and limits higher functioning residents’ opportunities for meaningful interactions. One recommendation is to design activity programs that include a wider range of activities that accommodate residents with differing functional ability. Examples might include tiered exercise programs designed for residents with varying physical abilities and creation of small group activities, such as bridge groups or book clubs, that can attract residents with similar interests and cognitive ability.
Although males are in the minority in AL, this group is growing. In addition to complaining that activities are “childish,” we often hear male residents complain that activities are geared more toward women. Designing activities that are more “male-oriented” and can promote meaningful interactions among male residents may potentially be an important strategy.
We also have observed meaningful relationships develop among residents with significant dementia. Designing activities that can promote meaningful interactions among these residents (ie, as opposed to activities that do not require active group interaction) also is recommended. Planning innovative activities that engage family members and others from the community also can help residents have access to meaningful interactions as well as develop and maintain a range of network ties. Good examples we have observed include organizing family cookouts, other types of special meals, or parties (eg, a Mardis Gras party), engaging residents in volunteer activities with community organizations, and holding a charity raffle at the facility. Events that involve the entire community of stakeholders (residents, AL staff, families, and others from the wider community) can help promote closer relationships among these groups. In some cases, we have observed supportive family members adopt residents who were not relatives but lacked family support of their own. Larger facility events that include a range of stakeholders can promote these types of positive outcomes. Other types of activities that attract larger groups of residents (ie, including those who might not participate in regularly scheduled weekly activities) and can promote meaningful interaction among residents include pet therapy, activities involving children from the community, and musical events.
Regular facility meals provide another important opportunity for helping residents create and maintain meaningful ties with co-residents. We find that it is helpful to seat residents together based on shared abilities, interests, and backgrounds. Findings reported in our study4 showed that repeated patterns of interaction over time may help break down relationship barriers that exist in AL. Results also show that these repeated interactions may be more successful when residents share more in common. With regard to one-on-one contexts with individual residents, we find that it is essential for LTC professionals to learn and be cognizant of individual resident’s abilities, preferences, and personal background, including changes in abilities and preferences as well as any other social challenges a resident might have.
Helping behavior is common in AL and can provide a rewarding role for higher functioning residents who are able to provide help for lower functioning residents and can help address stigma. Finding safe ways to promote helping behavior can be another effective strategy to help residents develop and maintain rewarding roles as well as develop meaningful co-resident relationships. Examples might include encouraging higher functioning residents to help lead or plan activities, such as bingo or Bible study.
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