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Life satisfaction in women with postmenopausal osteoporosis of the spine Janice C. Hallal RN, DNSc
a
a
School of Nursing , Catholic University of America , Washington, DC Published online: 14 Aug 2009.
To cite this article: Janice C. Hallal RN, DNSc (1991) Life satisfaction in women with postmenopausal osteoporosis of the spine, Health Care for Women International, 12:1, 99-110, DOI: 10.1080/07399339109515930 To link to this article: http://dx.doi.org/10.1080/07399339109515930
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
LIFE SATISFACTION IN WOMEN WITH POSTMENOPAUSAL OSTEOPOROSIS OF THE SPINE Janice C. Hallal, RN, DNSc
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School of Nursing Catholic University of America Washington, DC
This exploratory-descriptive study was undertaken to determine what combination of variables was the best predictor of life satisfaction in women with postmenopausal osteoporosis of the spine and vertebral fractures. A sample of 93 women, drawn from private osteoporosis clinics, completed the four research questionnaires. Data were analyzed using means, standard deviations, product-moment correlations, and stepwise multiple regression analysis. Analysis of the data revealed that there were significant predictors of life satisfaction in this group. Life satisfaction was best predicted by the following combination of variables: income level, frequency of back pain, perceived internal control over health, and perceived social support.
Osteoporosis, which is defined as a decrease in bone mass and strength and which leads to an increase in fractures (Raisz, 1988), is becoming an increasingly significant public health problem as the percentage of older persons in the population increases. This condition affects as many as 1520 million persons in the United States (National Institutes of Health, 1984). In accordance with the above definition, although osteoporosis must exist before an associated fracture occurs, many authorities contend that a person can be diagnosed as having osteoporosis only when a fracture due to bone loss has, indeed, occurred. Specifically, osteoporosis is responsible for at least 1.2 million fractures in the United States each year (Riggs & Melton, 1986). Approximately 40% of these fractures are vertebral, 20% are femoral, 15% are distal forearm, and the remaining 25% are of other skeletal sites (Licata, 1988). The financial burden of osteoporosis in the United States is in excess of $6 billion annually, considering
This study was partially supported by Grant No. 5 R21 NU 00 824 OS from the Division of Nursing, U.S. Department of Health and Human Services. Health Care for Women International, 12:99-110, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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both direct and indirect costs (Holbrook, Grazier, Kelsey, & Stauffer, 1984). Postmenopausal women are especially at risk for developing osteoporosis and the concomitant fractures (Nordin, 1983). The particular focus of this study is women who have postmenopausal osteoporosis of the spine as evidenced by one or more vertebral fractures. Vertebral fractures that occur as a result of postmenopausal osteoporosis are exceedingly common. It is estimated that 1 out of 4 women in the United States (9 million total) will experience an osteoporotic fracture of the spine by age 60. One out of 2 women (18 million total) will have had an osteoporotic fracture by age 75 (Gorrie, 1982). Interestingly, despite the high incidence of postmenopausal osteoporosis of the spine and vertebral fractures, no studies investigating the psychosocial aspects of this condition were found in the literature. MacPherson (1985) presented a feminist perspective of osteoporosis and urged descriptive studies that document perceptions of the disease from the woman's point of view. Studies are also needed that investigate psychosocial variables associated with postmenopausal osteoporosis. Changes in opportunities for social contact, level of independence, and body image may occur as a result of the pain, physical deformity, and disability that typically accompany postmenopausal osteoporosis of the spine and vertebral fractures (Hallal, 1985). The purpose of this initial exploratory-descriptive study is to determine what combination of variables is the best predictor of life satisfaction in women with postmenopausal osteoporosis of the spine and vertebral fractures. Many variables have been demonstrated to be associated with life satisfaction. The selection of variables for this study was based on findings from previous research. In addition, the variables were conceptualized based on the cognitive framework proposed by Lazarus and Cohen (1976). Specifically, they viewed the impact of inputs to the person on adaptive outcomes as being mediated by psychological factors. Input variables in this study included demographic variables (age, marital status, income level, and educational level) and pain variables (presence, frequency, duration, and severity). Mediating variables included perceived social support and perceived control over health. The outcome variable was life satisfaction. RELATED LITERATURE As previously mentioned, no studies were located in the literature that reported research on any psychosocial variable associated with postmenopausal osteoporosis of the spine. However, as osteoporosis is a
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chronic illness, it is appropriate to selectively review literature related to life satisfaction, perceived control over health, and perceived social support in chronic illness.
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Life Satisfaction Several nursing studies exploring life satisfaction, quality of life, or psychological well-being in relation to a chronic illness are reviewed in this article. Lambert (1985) studied factors associated with psychological well-being in 92 women with rheumatoid arthritis. In particular, she investigated the relationship of social support, severity of illness, and selected demographic characteristics to psychological well-being. The variable pain was the single significant predictor of psychological wellbeing within this group. Pain was negatively correlated with psychological well-being. Laborde and Powers (1985) studied life satisfaction in 160 persons with osteoarthritis. In particular, they explored the relationships between life satisfaction and health perception, health locus of control, and various illness-related factors. The researchers found that life satisfaction was related to better health perception, internal locus of control, and less joint pain. Burckhardt (1985) studied quality of life in 94 persons with arthritis. She measured quality of life, severity of pain, socioeconomic status, social network configuration, perceived support, severity of impairment, self-esteem, internal control over health, negative attitude toward illness, and general demographic and illness history data. Analysis showed that positive self-esteem, internal control over health, perceived support, and low negative attitude toward the illness contributed directly to a higher quality of life. Magilvy (1985) studied quality of life in 66 hearing-impaired older women. Variables studied included age, age at onset of hearing loss, financial adequacy, social hearing handicap, perceived health, and functional social support. Results showed the best predictors of quality of life to be the following: social hearing handicap, functional social support, and perceived health. Padilla and Grant (1985) studied quality of life in 135 cancer patients. Specifically, they investigated satisfaction with nursing care and personal control as cognitive mediators of self-worth, which would then presumably affect quality of life. They found that "as confidence in the nurse increased, internality increased, and chance decreased as an illness-wellness cause, then overall quality of life increased" (pp. 5657).
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Perceived Control over Health In addition to the findings of the previously mentioned Laborde and Powers (1985), Burckhardt (1985), and Padilla and Grant (1985) studies in relation to perceived control, results from two other relevant studies are described. Lewis (1982) examined the association of personal control and quality of life in 57 late-stage cancer patients. Quality of life was measured by level of self-esteem, level of anxiety, and perceived life meaningfulness. Findings show that the experience of personal control over one's life, as measured by a single item, was significantly correlated with the three quality-of-life measures. Lowery and Jacobsen (1985) analyzed attribution of chronic illness outcomes in a total of 296 persons with one of three chronic illnesses (arthritis, diabetes, or hypertension). The researchers investigated the causal attributions for success and failure outcomes in these persons. In general, participants tended to attribute success internally and failure externally. Social Support In addition to the findings of the previously mentioned Lambert (1985), Burckhardt (1985), and Magilvy (1985) studies in relation to social support, results from two other relevant studies are described. McNett (1987) studied the effects of social support variables, threat appraisal, and coping responses on coping effectiveness in 50 functionally disabled, wheelchair-bound individuals. Findings indicated that perceived social support, but not use of social support, was significantly related to coping effectiveness. Northouse (1988) investigated the nature of the relationship between social support and the adjustment of 50 mastectomy patients and their husbands. Northouse found that for both patients and husbands who reported higher levels of social support, there were fewer adjustment difficulties reported at both 3 and 30 days after surgery. METHOD Sample The participants were 93 women with diagnosed postmenopausal osteoporosis of the spine and one or more vertebral fractures. Additionally, the women had to be able to speak, write, and read English and had to be free of other serious medical or psychiatric illness. Several private osteoporosis clinics in the greater metropolitan area of a large eastern
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city in the United States were used to procure participants. Each participant was informed of the study's purpose and the extent of her participation. Written consent was obtained. Instruments
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Three self-administered questionnaires and a demographic and illness history and knowledge form were used to collect data. Approximately 45 min were required for completion of the questionnaires. Salamon-Conte Life Satisfaction in the Elderly Scale Numerous instruments are available to measure life satisfaction or quality of life. The Life Satisfaction in the Elderly Scale (LSES) was used to measure life satisfaction in this study. The LSES consists of the following eight subscales: daily activities, meaning, goals, mood, health, self-concept, finances, and social contacts. The instrument consists of 40 items (5 for each subscale) to which the participant responds. Items reflect a Likert format with a 5-point range. A total score on the LSES is obtained by adding the scores on the eight subscales. The total score can range from 40 to 200. Internal consistency and test-retest reliability have been established (Salamon & Conte, 1984). Norbeck Social Support Questionnaire The Norbeck Social Support Questionnaire (NSSQ) was selected from among numerous instruments to measure perceived social support. The NSSQ was developed by Norbeck, Lindsey, and Carrieri (1981, 1983) and was designed to measure multiple dimensions of social support. Respondents are asked to list up to 20 social network members and to answer eight questions relative to each member. Six of the questions relate to the functional properties of social support, which are defined as affect, affirmation, and aid. Respondents are asked to rate each social network member on a 5-point Likert-type scale. Two questions request information concerning the duration of the relationship and the frequency of contact with each social network member listed. The ninth question asks the respondent for information about recent losses of social support. Only measures of the dimensions of functional social support (affect, affirmation, and aid) were used in the present study. Test-retest reliability, internal consistency, and concurrent, construct, discriminant, and predictive validity have been demonstrated for the NSSQ. Multidimensional Health Locus of Control Scales The Multidimensional Health Locus of Control (MHLC) Scales were used in this study to measure perceived control over health. This instru-
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ment was developed by Wallston, Wallston, and DeVellis (1978) and consists of three subscales that measure the internal, powerful others, and chance health loci of control. Each subscale is a Likert-type scale consisting of six statements to which the participant responds on an agree-disagree continuum. There are a total of 18 statements to which the participant responds (6 on each subscale). Test-retest reliability and predictive validity have been established.
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Demographic and Illness History and Knowledge Form
On the 38-item Demographic and Illness History and Knowledge Form, participants were asked to respond to questions covering topics such as demographic information, pain experience with osteoporosis of the spine, and health knowledge about osteoporosis and calcium. The format included primarily closed-ended questions, but several openended questions were also included. This instrument was submitted to a panel of judges knowledgeable in osteoporosis for the establishment of content validity. Procedure All women who met the selection criteria were invited to participate in the study until a sufficient number of participants had been obtained. Eligible and willing participants were asked to complete the research instruments. Analysis Data were analyzed using descriptive statistics, product-moment correlations, and stepwise multiple regression analysis. RESULTS The average age of the 93 participants was 62.3 years. Sixty-one (66%) of the women were currently married. Seventy-six (82%) of the women had children. Income levels varied widely, ranging from less than $10,000 per year to more than $50,000 per year. However, 43 (54%) of the women reported yearly incomes of from $10,000 to $40,000. Fourteen (15%) of the women declined to give information concerning income level. Educational levels also varied widely, ranging from less than high school graduation to completion of a graduate or professional degree. One third (33%) had ended their formal schooling with graduation from high school. An additional 26 (28%) had some college work and 32 (34%) were college graduates. Of the 91 women
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who provided information about their employment or volunteer status, 53 (58%) had regular employment or volunteer duties. In response to a series of questions concerning the experience of pain with postmenopausal osteoporosis of the spine and vertebral fractures, a number of interesting findings emerged. Seventy-six (83%) of the women reported that they had back pain. Detailed analyses of the frequency, duration, and severity of the back pain are reported elsewhere. In general, however, these dimensions were found to vary fairly widely. Table 1 presents the means, standard deviations, and ranges of the sample on the LSES, the NSSQ, and the MHLC Scales. Table 2 presents correlations between the dependent variable, life satisfaction, and the independent variables. A number of significant relationships were discovered. To determine what combination of variables was most predictive of life satisfaction, a stepwise multiple regression analysis was done. In entering variables into the regression, demographic variables were entered as a block, the pain variables were then entered as a block, and then the mediating variables of perceived social support and perceived control over health were entered. Tables 3 and 4 present the results of two stepwise multiple regression analyses. As previously mentioned, 14 participants declined to give information relative to income level. Table 3, therefore, is an analysis of the data for the 79 participants for whom complete data were collected. Table 4 is an analysis of the data for all 93 participants with the variable of income level deleted. Table 3 shows that income level is the most important predictor of life satisfaction and accounts for slightly more than 30% of the variance in life satisfaction. Age enters at Step 2 and accounts for slightly more than 3.6% of the variance remaining once income level has been considered. Frequency of back pain enters at Step 3 and accounts for slightly more than 4.6% of the variance remaining when both income level and age have been considered. Perceived internal control enters at Step 4 and accounts for slightly more than 9.6% of the variance remaining when income level, age, and frequency of back pain have been considered. Perceived social support-affirmation enters at Step 5 and accounts for slightly more than 2.7% of the variance remaining when the contributions of all the above variables have been considered. In summary, by using the following five predictor variables, higher income level, older age, less frequent back pain, perceived internal control, and a higher level of perceived social support, as measured by the affirmation dimension, it is possible to explain 50.5% of the variance in life satisfaction. Table 4 presents the analysis with the variable income level deleted and shows similar but somewhat different results. At Step 1, marital
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Table 1. Means, Standard Deviations, and Range of Scores of Sample on Three Instruments M
SD
Range
LSES
140.89
16.74
85-177
NSSQ Affect Affirmation Aid Total functional
98.54 86.71 76.02 261.27
55.11 • 46.13 42.62 139.50
10-240 9-229 9-207 28-616
26.03 18.24 15.41
4.75 5.37 5.37
15-36 6-34 6-31
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Instrument
MHLC Scales Internal Powerful others Chance
Note. N - 93. LSES - Life Satisfaction in the Elderly Scale, NSSQ - Norbeck Social Support Questionnaire, MHLC — Multidimensional Health Locus of Control Scales. Table 2. Product-Moment Correlations with Life Satisfaction Variable Social support Affect Affirmation Aid Total functional Perceived control Internal Powerful others Chance Age Marital status Income level Educational level Presence of pain Frequency of pain Duration of pain Severity of pain
Na
r
P
93 93 93 93
.1937 .2104 .2039 .2084
.031 .021 .025 .023
93 93 93 93 93 79 93 93 93 93 93
.3162 -.1674 - .0869 .0528 .3706 .5470 .0982 -.2134 - .3706 -.3145 -.3011
.001 .054 .204 .307 .001 .001 .174 .020 .001 .001 .002
"ff less than 93 exists for "income level" due to missing data.
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Table 3. Stepwise Regression (Life Satisfaction as Dependent Variable) (N = 79) Step
Variable
1 2 3 4
Income level Age Frequency of back pain Perceived controlinternal Perceived social supportaffirmation
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5
Adjusted ii 2
F value
.3024 .3387 .3850 .5553
.2933 .3213 .3604 .5248
33.376* 19.461* 15.650* 18.232*
.5824
.5476
16.736*
*p < .001.
status (in this case, being married) accounts for nearly 14% of the variance in life satisfaction. It is a documented fact that, for women, being married is positively correlated with a higher income level. Therefore, with the variable income deleted, the variable marital status assumes importance. Frequency of back pain enters at Step 2 and accounts for nearly 13% of the variance remaining once marital status has been considered. Perceived internal control enters at Step 3 and accounts for slightly more than 8% of the variance remaining when the contributions of the above variables have been considered. In summary, by using the set of the following three predictor variables, being married, less frequent back pain, and perceived internal control, it is possible to explain 35% of the variance in life satisfaction. DISCUSSION A number of interesting and important findings emerged from the data analysis. The finding that more than 30% of life satisfaction is accounted for by income level is particularly interesting. One is left to Table 4. Stepwise Regression (Life Satisfaction as Dependent Variable) (N = 93) Step
Variable
i?2
Adjusted/t 2
F value
1 2 3
Marital status Frequency of back pain Perceived control—internal
.1371 .2640 .4397
.1275 .2475 .4139
14.295* 15.964* 17.068*
*p < .001.
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wonder whether any of the women at the lower income levels are actually in need of any of life's necessities. Or it may be that their current standard of living is a reduction from their former standard of living, representing a relative deprivation. Either actual or relative deprivation could contribute to a lowered life satisfaction. The age variable (specifically, being older) is a somewhat curious addition to the regression equation in view of the fact that age was not significantly correlated with life satisfaction by the product-moment correlation. Age entered the regression equation primarily because of its correlation with income level and, therefore, in real terms does not act as an important predictor of life satisfaction. When income level is not considered as a variable, marital status functions as a fairly strong predictor of life satisfaction. As previously mentioned, married women, in general, have higher income levels. This was indeed true of the current sample. Of the pain characteristics, frequency of back pain was the strongest predictor of life satisfaction. It should be noted that all four pain characteristics (presence, frequency, duration, and severity) were highly correlated, as expected. Perceived internal control over health was also an important predictor of life satisfaction. This finding is in accordance with the findings of the Burckhardt (1985), Laborde and Powers (1985), Lewis (1982), and Padilla and Grant (1985) studies. Perceived control by chance and by powerful others were both negatively correlated with life satisfaction. Perceived social support, as measured by the affirmation dimension only, was also a predictor of life satisfaction. The variables affect, aid and total functional were all highly correlated with affirmation, as well' as with each other. The findings of this study in relation to perceived social support are in accordance with the findings of the Burckhardt (1985), Magilvy (1985), McNett (1987), and Northouse (1988) studies. For this particular sample, it was possible to identify a fairly potent set of predictors of life satisfaction. Whether this set of predictors would hold true for any other sample is, of course, unknown. However, based on the findings of this study, several implications for health care are identified. At the direct-care level, health professionals may be directed to perform a more focused assessment of women with postmenopausal osteoporosis of the spine and vertebral fractures. In a broader sense, this study marks the beginning of establishment of client variables associated with life satisfaction in one very common chronic illness, postmenopausal osteoporosis of the spine. Obviously, this research represents only a beginning step toward a fuller understanding of the entire range of psychosocial variables asso-
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ciated with postmenopausal osteoporosis, as well as specific coping strategies.
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REFERENCES Burckhardt, C. S. (1985). The impact of arthritis on quality of life. Nursing Research, 34, 11-16. Gorrie, T. M. (1982). Postmenopausal osteoporosis. Journal of Obstetric, Gynecological, and Neonatal Nursing, 11, 214-219. Hallal, J. C. (1985). Osteoporotic fractures exact a toll. Journal of Gerontological Nursing, 11(8), 13-19. Holbrook, T. L., Grazier, K., Kelsey, J. L., & Stauffer, R. N. (1984). The frequency of occurrence, impact and cost of selected musculoskeletal conditions in the United States. Chicago: American Academy of Orthopedic Surgeons. Laborde, J. M., & Powers, M. J. (1985). Life satisfaction, health orientation, and illness-related factors in persons with osteoarthritis. Research in Nursing and Health Care, 8, 183-190. Lambert, V. A. (1985). Study of factors associated with psychological well-being in rheumatoid arthritic women. Image: The Journal of Nursing Scholarship, 17, 50-53. Lazarus, R. S., & Cohen, J. B. (1976, June). Study of stress and coping in aging. Paper presented at the 5th WHO Conference on Society and Disease: Aging and Old Age, Stockholm, Sweden. Lewis, F. M. (1982). Experienced personal control and quality of life in late-stage cancer patients. Nursing Research, 31, 113-119. Licata, A. A. (1988). Some thoughts on osteoporosis in women. Cleveland Clinic Journal of Medicine, 55, 233-238. Lowery, B. J., & Jacobsen, B. S. (1985). Attributional analysis of chronic illness outcomes. Nursing Research, 34, 82-88. MacPherson, K. I. (1985). Osteoporosis and menopause: A feminist analysis of the social construction of a syndrome. Advances in Nursing Science, 7(4), 11-22. Magilvy, J. K. (1985). Quality of life in hearing-impaired older women. Nursing Research, 34, 140-144. McNett, S. C. (1987). Social support, threat, and coping responses and effectiveness in the functionally disabled. Nursing Research, 36, 98-103. National Institutes of Health. (1984). Consensus development conference statement on osteoporosis. Bethesda, MD: U.S. Department of Health and Human Services. Norbeck, J. S., Lindsey, A. M., & Carried, V. L. (1981). The development of an instrument to measure social support. Nursing Research, 30, 264-269. Norbeck, J. S., Lindsey, A. M., & Carrieri, V. L. (1983). Further development of the Norbeck Social Support Questionnaire: Normative data and validity testing. Nursing Research, 32, 4-9. Nordin, B. E. C. (1983). Osteoporosis with particular reference to the menopause. In L. V. Avioli (Ed.), The osteoporotic syndrome: Detection, prevention, and treatment (pp. 13-43). New York: Grune & Stratton. Northouse, L. L. (1988). Social support in patients' and husbands' adjustment to breast cancer. Nursing Research, 37, 91-95.
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Padilla, G. V., & Grant, M. M. (1985). Quality of life as a cancer nursing outcome variable. Advances in Nursing Science, 8(1), 45-60. Raisz, L. G. (1988). Local and systemic factors in the pathogenesis of osteoporosis. New England Journal of Medicine, 318, 818-828. Riggs, B. L., & Melton, L. J. (1986). Involutional osteoporosis. New England Journal of Medicine, 314, 1676-1684. Salamon, M. J., & Conte, V. A. (1984). Salamon-Conte Life Satisfaction in the Elderly Scale (test manual). Odessa, FL: Psychological Assessment Resources. Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6, 160-170.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
Life satisfaction in women with postmenopausal osteoporosis of the spine Janice C. Hallal RN, DNSc
a
a
School of Nursing , Catholic University of America , Washington, DC Published online: 14 Aug 2009.
To cite this article: Janice C. Hallal RN, DNSc (1991) Life satisfaction in women with postmenopausal osteoporosis of the spine, Health Care for Women International, 12:1, 99-110, DOI: 10.1080/07399339109515930 To link to this article: http://dx.doi.org/10.1080/07399339109515930
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
LIFE SATISFACTION IN WOMEN WITH POSTMENOPAUSAL OSTEOPOROSIS OF THE SPINE Janice C. Hallal, RN, DNSc
Downloaded by [University of Calgary] at 10:52 02 February 2015
School of Nursing Catholic University of America Washington, DC
This exploratory-descriptive study was undertaken to determine what combination of variables was the best predictor of life satisfaction in women with postmenopausal osteoporosis of the spine and vertebral fractures. A sample of 93 women, drawn from private osteoporosis clinics, completed the four research questionnaires. Data were analyzed using means, standard deviations, product-moment correlations, and stepwise multiple regression analysis. Analysis of the data revealed that there were significant predictors of life satisfaction in this group. Life satisfaction was best predicted by the following combination of variables: income level, frequency of back pain, perceived internal control over health, and perceived social support.
Osteoporosis, which is defined as a decrease in bone mass and strength and which leads to an increase in fractures (Raisz, 1988), is becoming an increasingly significant public health problem as the percentage of older persons in the population increases. This condition affects as many as 1520 million persons in the United States (National Institutes of Health, 1984). In accordance with the above definition, although osteoporosis must exist before an associated fracture occurs, many authorities contend that a person can be diagnosed as having osteoporosis only when a fracture due to bone loss has, indeed, occurred. Specifically, osteoporosis is responsible for at least 1.2 million fractures in the United States each year (Riggs & Melton, 1986). Approximately 40% of these fractures are vertebral, 20% are femoral, 15% are distal forearm, and the remaining 25% are of other skeletal sites (Licata, 1988). The financial burden of osteoporosis in the United States is in excess of $6 billion annually, considering
This study was partially supported by Grant No. 5 R21 NU 00 824 OS from the Division of Nursing, U.S. Department of Health and Human Services. Health Care for Women International, 12:99-110, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
99
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both direct and indirect costs (Holbrook, Grazier, Kelsey, & Stauffer, 1984). Postmenopausal women are especially at risk for developing osteoporosis and the concomitant fractures (Nordin, 1983). The particular focus of this study is women who have postmenopausal osteoporosis of the spine as evidenced by one or more vertebral fractures. Vertebral fractures that occur as a result of postmenopausal osteoporosis are exceedingly common. It is estimated that 1 out of 4 women in the United States (9 million total) will experience an osteoporotic fracture of the spine by age 60. One out of 2 women (18 million total) will have had an osteoporotic fracture by age 75 (Gorrie, 1982). Interestingly, despite the high incidence of postmenopausal osteoporosis of the spine and vertebral fractures, no studies investigating the psychosocial aspects of this condition were found in the literature. MacPherson (1985) presented a feminist perspective of osteoporosis and urged descriptive studies that document perceptions of the disease from the woman's point of view. Studies are also needed that investigate psychosocial variables associated with postmenopausal osteoporosis. Changes in opportunities for social contact, level of independence, and body image may occur as a result of the pain, physical deformity, and disability that typically accompany postmenopausal osteoporosis of the spine and vertebral fractures (Hallal, 1985). The purpose of this initial exploratory-descriptive study is to determine what combination of variables is the best predictor of life satisfaction in women with postmenopausal osteoporosis of the spine and vertebral fractures. Many variables have been demonstrated to be associated with life satisfaction. The selection of variables for this study was based on findings from previous research. In addition, the variables were conceptualized based on the cognitive framework proposed by Lazarus and Cohen (1976). Specifically, they viewed the impact of inputs to the person on adaptive outcomes as being mediated by psychological factors. Input variables in this study included demographic variables (age, marital status, income level, and educational level) and pain variables (presence, frequency, duration, and severity). Mediating variables included perceived social support and perceived control over health. The outcome variable was life satisfaction. RELATED LITERATURE As previously mentioned, no studies were located in the literature that reported research on any psychosocial variable associated with postmenopausal osteoporosis of the spine. However, as osteoporosis is a
Life Satisfaction in Women
101
chronic illness, it is appropriate to selectively review literature related to life satisfaction, perceived control over health, and perceived social support in chronic illness.
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Life Satisfaction Several nursing studies exploring life satisfaction, quality of life, or psychological well-being in relation to a chronic illness are reviewed in this article. Lambert (1985) studied factors associated with psychological well-being in 92 women with rheumatoid arthritis. In particular, she investigated the relationship of social support, severity of illness, and selected demographic characteristics to psychological well-being. The variable pain was the single significant predictor of psychological wellbeing within this group. Pain was negatively correlated with psychological well-being. Laborde and Powers (1985) studied life satisfaction in 160 persons with osteoarthritis. In particular, they explored the relationships between life satisfaction and health perception, health locus of control, and various illness-related factors. The researchers found that life satisfaction was related to better health perception, internal locus of control, and less joint pain. Burckhardt (1985) studied quality of life in 94 persons with arthritis. She measured quality of life, severity of pain, socioeconomic status, social network configuration, perceived support, severity of impairment, self-esteem, internal control over health, negative attitude toward illness, and general demographic and illness history data. Analysis showed that positive self-esteem, internal control over health, perceived support, and low negative attitude toward the illness contributed directly to a higher quality of life. Magilvy (1985) studied quality of life in 66 hearing-impaired older women. Variables studied included age, age at onset of hearing loss, financial adequacy, social hearing handicap, perceived health, and functional social support. Results showed the best predictors of quality of life to be the following: social hearing handicap, functional social support, and perceived health. Padilla and Grant (1985) studied quality of life in 135 cancer patients. Specifically, they investigated satisfaction with nursing care and personal control as cognitive mediators of self-worth, which would then presumably affect quality of life. They found that "as confidence in the nurse increased, internality increased, and chance decreased as an illness-wellness cause, then overall quality of life increased" (pp. 5657).
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Perceived Control over Health In addition to the findings of the previously mentioned Laborde and Powers (1985), Burckhardt (1985), and Padilla and Grant (1985) studies in relation to perceived control, results from two other relevant studies are described. Lewis (1982) examined the association of personal control and quality of life in 57 late-stage cancer patients. Quality of life was measured by level of self-esteem, level of anxiety, and perceived life meaningfulness. Findings show that the experience of personal control over one's life, as measured by a single item, was significantly correlated with the three quality-of-life measures. Lowery and Jacobsen (1985) analyzed attribution of chronic illness outcomes in a total of 296 persons with one of three chronic illnesses (arthritis, diabetes, or hypertension). The researchers investigated the causal attributions for success and failure outcomes in these persons. In general, participants tended to attribute success internally and failure externally. Social Support In addition to the findings of the previously mentioned Lambert (1985), Burckhardt (1985), and Magilvy (1985) studies in relation to social support, results from two other relevant studies are described. McNett (1987) studied the effects of social support variables, threat appraisal, and coping responses on coping effectiveness in 50 functionally disabled, wheelchair-bound individuals. Findings indicated that perceived social support, but not use of social support, was significantly related to coping effectiveness. Northouse (1988) investigated the nature of the relationship between social support and the adjustment of 50 mastectomy patients and their husbands. Northouse found that for both patients and husbands who reported higher levels of social support, there were fewer adjustment difficulties reported at both 3 and 30 days after surgery. METHOD Sample The participants were 93 women with diagnosed postmenopausal osteoporosis of the spine and one or more vertebral fractures. Additionally, the women had to be able to speak, write, and read English and had to be free of other serious medical or psychiatric illness. Several private osteoporosis clinics in the greater metropolitan area of a large eastern
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city in the United States were used to procure participants. Each participant was informed of the study's purpose and the extent of her participation. Written consent was obtained. Instruments
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Three self-administered questionnaires and a demographic and illness history and knowledge form were used to collect data. Approximately 45 min were required for completion of the questionnaires. Salamon-Conte Life Satisfaction in the Elderly Scale Numerous instruments are available to measure life satisfaction or quality of life. The Life Satisfaction in the Elderly Scale (LSES) was used to measure life satisfaction in this study. The LSES consists of the following eight subscales: daily activities, meaning, goals, mood, health, self-concept, finances, and social contacts. The instrument consists of 40 items (5 for each subscale) to which the participant responds. Items reflect a Likert format with a 5-point range. A total score on the LSES is obtained by adding the scores on the eight subscales. The total score can range from 40 to 200. Internal consistency and test-retest reliability have been established (Salamon & Conte, 1984). Norbeck Social Support Questionnaire The Norbeck Social Support Questionnaire (NSSQ) was selected from among numerous instruments to measure perceived social support. The NSSQ was developed by Norbeck, Lindsey, and Carrieri (1981, 1983) and was designed to measure multiple dimensions of social support. Respondents are asked to list up to 20 social network members and to answer eight questions relative to each member. Six of the questions relate to the functional properties of social support, which are defined as affect, affirmation, and aid. Respondents are asked to rate each social network member on a 5-point Likert-type scale. Two questions request information concerning the duration of the relationship and the frequency of contact with each social network member listed. The ninth question asks the respondent for information about recent losses of social support. Only measures of the dimensions of functional social support (affect, affirmation, and aid) were used in the present study. Test-retest reliability, internal consistency, and concurrent, construct, discriminant, and predictive validity have been demonstrated for the NSSQ. Multidimensional Health Locus of Control Scales The Multidimensional Health Locus of Control (MHLC) Scales were used in this study to measure perceived control over health. This instru-
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ment was developed by Wallston, Wallston, and DeVellis (1978) and consists of three subscales that measure the internal, powerful others, and chance health loci of control. Each subscale is a Likert-type scale consisting of six statements to which the participant responds on an agree-disagree continuum. There are a total of 18 statements to which the participant responds (6 on each subscale). Test-retest reliability and predictive validity have been established.
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Demographic and Illness History and Knowledge Form
On the 38-item Demographic and Illness History and Knowledge Form, participants were asked to respond to questions covering topics such as demographic information, pain experience with osteoporosis of the spine, and health knowledge about osteoporosis and calcium. The format included primarily closed-ended questions, but several openended questions were also included. This instrument was submitted to a panel of judges knowledgeable in osteoporosis for the establishment of content validity. Procedure All women who met the selection criteria were invited to participate in the study until a sufficient number of participants had been obtained. Eligible and willing participants were asked to complete the research instruments. Analysis Data were analyzed using descriptive statistics, product-moment correlations, and stepwise multiple regression analysis. RESULTS The average age of the 93 participants was 62.3 years. Sixty-one (66%) of the women were currently married. Seventy-six (82%) of the women had children. Income levels varied widely, ranging from less than $10,000 per year to more than $50,000 per year. However, 43 (54%) of the women reported yearly incomes of from $10,000 to $40,000. Fourteen (15%) of the women declined to give information concerning income level. Educational levels also varied widely, ranging from less than high school graduation to completion of a graduate or professional degree. One third (33%) had ended their formal schooling with graduation from high school. An additional 26 (28%) had some college work and 32 (34%) were college graduates. Of the 91 women
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who provided information about their employment or volunteer status, 53 (58%) had regular employment or volunteer duties. In response to a series of questions concerning the experience of pain with postmenopausal osteoporosis of the spine and vertebral fractures, a number of interesting findings emerged. Seventy-six (83%) of the women reported that they had back pain. Detailed analyses of the frequency, duration, and severity of the back pain are reported elsewhere. In general, however, these dimensions were found to vary fairly widely. Table 1 presents the means, standard deviations, and ranges of the sample on the LSES, the NSSQ, and the MHLC Scales. Table 2 presents correlations between the dependent variable, life satisfaction, and the independent variables. A number of significant relationships were discovered. To determine what combination of variables was most predictive of life satisfaction, a stepwise multiple regression analysis was done. In entering variables into the regression, demographic variables were entered as a block, the pain variables were then entered as a block, and then the mediating variables of perceived social support and perceived control over health were entered. Tables 3 and 4 present the results of two stepwise multiple regression analyses. As previously mentioned, 14 participants declined to give information relative to income level. Table 3, therefore, is an analysis of the data for the 79 participants for whom complete data were collected. Table 4 is an analysis of the data for all 93 participants with the variable of income level deleted. Table 3 shows that income level is the most important predictor of life satisfaction and accounts for slightly more than 30% of the variance in life satisfaction. Age enters at Step 2 and accounts for slightly more than 3.6% of the variance remaining once income level has been considered. Frequency of back pain enters at Step 3 and accounts for slightly more than 4.6% of the variance remaining when both income level and age have been considered. Perceived internal control enters at Step 4 and accounts for slightly more than 9.6% of the variance remaining when income level, age, and frequency of back pain have been considered. Perceived social support-affirmation enters at Step 5 and accounts for slightly more than 2.7% of the variance remaining when the contributions of all the above variables have been considered. In summary, by using the following five predictor variables, higher income level, older age, less frequent back pain, perceived internal control, and a higher level of perceived social support, as measured by the affirmation dimension, it is possible to explain 50.5% of the variance in life satisfaction. Table 4 presents the analysis with the variable income level deleted and shows similar but somewhat different results. At Step 1, marital
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Table 1. Means, Standard Deviations, and Range of Scores of Sample on Three Instruments M
SD
Range
LSES
140.89
16.74
85-177
NSSQ Affect Affirmation Aid Total functional
98.54 86.71 76.02 261.27
55.11 • 46.13 42.62 139.50
10-240 9-229 9-207 28-616
26.03 18.24 15.41
4.75 5.37 5.37
15-36 6-34 6-31
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Instrument
MHLC Scales Internal Powerful others Chance
Note. N - 93. LSES - Life Satisfaction in the Elderly Scale, NSSQ - Norbeck Social Support Questionnaire, MHLC — Multidimensional Health Locus of Control Scales. Table 2. Product-Moment Correlations with Life Satisfaction Variable Social support Affect Affirmation Aid Total functional Perceived control Internal Powerful others Chance Age Marital status Income level Educational level Presence of pain Frequency of pain Duration of pain Severity of pain
Na
r
P
93 93 93 93
.1937 .2104 .2039 .2084
.031 .021 .025 .023
93 93 93 93 93 79 93 93 93 93 93
.3162 -.1674 - .0869 .0528 .3706 .5470 .0982 -.2134 - .3706 -.3145 -.3011
.001 .054 .204 .307 .001 .001 .174 .020 .001 .001 .002
"ff less than 93 exists for "income level" due to missing data.
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Table 3. Stepwise Regression (Life Satisfaction as Dependent Variable) (N = 79) Step
Variable
1 2 3 4
Income level Age Frequency of back pain Perceived controlinternal Perceived social supportaffirmation
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5
Adjusted ii 2
F value
.3024 .3387 .3850 .5553
.2933 .3213 .3604 .5248
33.376* 19.461* 15.650* 18.232*
.5824
.5476
16.736*
*p < .001.
status (in this case, being married) accounts for nearly 14% of the variance in life satisfaction. It is a documented fact that, for women, being married is positively correlated with a higher income level. Therefore, with the variable income deleted, the variable marital status assumes importance. Frequency of back pain enters at Step 2 and accounts for nearly 13% of the variance remaining once marital status has been considered. Perceived internal control enters at Step 3 and accounts for slightly more than 8% of the variance remaining when the contributions of the above variables have been considered. In summary, by using the set of the following three predictor variables, being married, less frequent back pain, and perceived internal control, it is possible to explain 35% of the variance in life satisfaction. DISCUSSION A number of interesting and important findings emerged from the data analysis. The finding that more than 30% of life satisfaction is accounted for by income level is particularly interesting. One is left to Table 4. Stepwise Regression (Life Satisfaction as Dependent Variable) (N = 93) Step
Variable
i?2
Adjusted/t 2
F value
1 2 3
Marital status Frequency of back pain Perceived control—internal
.1371 .2640 .4397
.1275 .2475 .4139
14.295* 15.964* 17.068*
*p < .001.
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wonder whether any of the women at the lower income levels are actually in need of any of life's necessities. Or it may be that their current standard of living is a reduction from their former standard of living, representing a relative deprivation. Either actual or relative deprivation could contribute to a lowered life satisfaction. The age variable (specifically, being older) is a somewhat curious addition to the regression equation in view of the fact that age was not significantly correlated with life satisfaction by the product-moment correlation. Age entered the regression equation primarily because of its correlation with income level and, therefore, in real terms does not act as an important predictor of life satisfaction. When income level is not considered as a variable, marital status functions as a fairly strong predictor of life satisfaction. As previously mentioned, married women, in general, have higher income levels. This was indeed true of the current sample. Of the pain characteristics, frequency of back pain was the strongest predictor of life satisfaction. It should be noted that all four pain characteristics (presence, frequency, duration, and severity) were highly correlated, as expected. Perceived internal control over health was also an important predictor of life satisfaction. This finding is in accordance with the findings of the Burckhardt (1985), Laborde and Powers (1985), Lewis (1982), and Padilla and Grant (1985) studies. Perceived control by chance and by powerful others were both negatively correlated with life satisfaction. Perceived social support, as measured by the affirmation dimension only, was also a predictor of life satisfaction. The variables affect, aid and total functional were all highly correlated with affirmation, as well' as with each other. The findings of this study in relation to perceived social support are in accordance with the findings of the Burckhardt (1985), Magilvy (1985), McNett (1987), and Northouse (1988) studies. For this particular sample, it was possible to identify a fairly potent set of predictors of life satisfaction. Whether this set of predictors would hold true for any other sample is, of course, unknown. However, based on the findings of this study, several implications for health care are identified. At the direct-care level, health professionals may be directed to perform a more focused assessment of women with postmenopausal osteoporosis of the spine and vertebral fractures. In a broader sense, this study marks the beginning of establishment of client variables associated with life satisfaction in one very common chronic illness, postmenopausal osteoporosis of the spine. Obviously, this research represents only a beginning step toward a fuller understanding of the entire range of psychosocial variables asso-
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ciated with postmenopausal osteoporosis, as well as specific coping strategies.
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REFERENCES Burckhardt, C. S. (1985). The impact of arthritis on quality of life. Nursing Research, 34, 11-16. Gorrie, T. M. (1982). Postmenopausal osteoporosis. Journal of Obstetric, Gynecological, and Neonatal Nursing, 11, 214-219. Hallal, J. C. (1985). Osteoporotic fractures exact a toll. Journal of Gerontological Nursing, 11(8), 13-19. Holbrook, T. L., Grazier, K., Kelsey, J. L., & Stauffer, R. N. (1984). The frequency of occurrence, impact and cost of selected musculoskeletal conditions in the United States. Chicago: American Academy of Orthopedic Surgeons. Laborde, J. M., & Powers, M. J. (1985). Life satisfaction, health orientation, and illness-related factors in persons with osteoarthritis. Research in Nursing and Health Care, 8, 183-190. Lambert, V. A. (1985). Study of factors associated with psychological well-being in rheumatoid arthritic women. Image: The Journal of Nursing Scholarship, 17, 50-53. Lazarus, R. S., & Cohen, J. B. (1976, June). Study of stress and coping in aging. Paper presented at the 5th WHO Conference on Society and Disease: Aging and Old Age, Stockholm, Sweden. Lewis, F. M. (1982). Experienced personal control and quality of life in late-stage cancer patients. Nursing Research, 31, 113-119. Licata, A. A. (1988). Some thoughts on osteoporosis in women. Cleveland Clinic Journal of Medicine, 55, 233-238. Lowery, B. J., & Jacobsen, B. S. (1985). Attributional analysis of chronic illness outcomes. Nursing Research, 34, 82-88. MacPherson, K. I. (1985). Osteoporosis and menopause: A feminist analysis of the social construction of a syndrome. Advances in Nursing Science, 7(4), 11-22. Magilvy, J. K. (1985). Quality of life in hearing-impaired older women. Nursing Research, 34, 140-144. McNett, S. C. (1987). Social support, threat, and coping responses and effectiveness in the functionally disabled. Nursing Research, 36, 98-103. National Institutes of Health. (1984). Consensus development conference statement on osteoporosis. Bethesda, MD: U.S. Department of Health and Human Services. Norbeck, J. S., Lindsey, A. M., & Carried, V. L. (1981). The development of an instrument to measure social support. Nursing Research, 30, 264-269. Norbeck, J. S., Lindsey, A. M., & Carrieri, V. L. (1983). Further development of the Norbeck Social Support Questionnaire: Normative data and validity testing. Nursing Research, 32, 4-9. Nordin, B. E. C. (1983). Osteoporosis with particular reference to the menopause. In L. V. Avioli (Ed.), The osteoporotic syndrome: Detection, prevention, and treatment (pp. 13-43). New York: Grune & Stratton. Northouse, L. L. (1988). Social support in patients' and husbands' adjustment to breast cancer. Nursing Research, 37, 91-95.
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Padilla, G. V., & Grant, M. M. (1985). Quality of life as a cancer nursing outcome variable. Advances in Nursing Science, 8(1), 45-60. Raisz, L. G. (1988). Local and systemic factors in the pathogenesis of osteoporosis. New England Journal of Medicine, 318, 818-828. Riggs, B. L., & Melton, L. J. (1986). Involutional osteoporosis. New England Journal of Medicine, 314, 1676-1684. Salamon, M. J., & Conte, V. A. (1984). Salamon-Conte Life Satisfaction in the Elderly Scale (test manual). Odessa, FL: Psychological Assessment Resources. Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6, 160-170.
