AUTHORS
Mohammed Shahadat Uddin
Dr. Liaquat Hossain

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INTRODUCTION AND BACKGROUND

The enhancement of and inventions in medical science reduces the incidence of many fatal diseases and makes the treatment of some of these diseases more available and is now supporting longevity of people (Ryan and Willits 2007). It is quite common that people entering old age tend to become dependent on others and put more influence on their personal networks regarding their activities of daily living and health related issues (Dowd 1984). After a lifetime of typically giving more to younger persons than they receive from them, elders must come to accept beneficence as like parents receiving benefits from child (Dowd 1975; Dowd 1984). This can be explained as getting benefits from past contributions. However, receiving this kind of benefit might be a problem as elders may have less to offer to balance the relationships with others (Su and Ferraro 1997). Elders also may get benefits as a way of emotional sharing, awareness of positive health behavior from their social network. Thus, with the increase of life and influence to their social networks, elders become more dependent to their family network.

Throughout this paper, we treat social network and family network as two classifications of individual personal network, which has been found to play an important role on human health outcomes (Kaplan and Hartwell 1987; Berkman 1995; Farmer, Meyer et al. 1996; Seeman 1996). To distinguish between social network and family network, we refer all relationships with non-relatives as well as distance relatives, belong to social network; whereas, family network is referred to relations with direct family members such as parent, son and daughter, brother and sister. The benefits that people may receive from their personal network could be (i) emotional, such as intimacy and attachment, reassurance, and the knowledge that one can confide in and rely on another; (ii) instrumental, such as direct financial aid or services; and (iii) informational, such as assistance with problem solving or provision of feedback (Cohen and Syme 1985). Conversely, previous research also suggests that social isolation may produce undesirable changes such as lower immune function, and higher neuroendocrine and cardiovascular reactivity in the body, all of which may increase susceptibility to diseases (ORTH-GOMER, UNDEN et al. 1988; Seeman 1996; Berkman, Melchior et al. 2004).

Health is no longer considered as a one-dimensional experience; instead it incorporates physical, mental, and psychological aspects of well-being. Health has been regarded as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO 1958). It follows that in order to be healthy, physical fitness, being of sound mind, and social wellness which is the ability to form and maintain social and family network, all are equally important. As defined by World Health Organisation, physical health is good body health; whereas, mental health refers to a state of emotional and social wellbeing of an individual reflecting on his or her ability to cope with the normal stress of life. It describes the capacity of individuals to interact, inclusively and equitably, with one another and with the surrounding environment in ways that promote subjective wellbeing, and optimize opportunities for development and the use of mental abilities (Fox 2007). Psychological health concerns with the current feelings of normal individuals toward distress and happiness, whether their lives are satisfying and productive, and whether they find lives to be interesting or depressed. In general, psychological health has to do with the question: "how are you doing?"

Different aspects of health of elder people are related not only to their income (Smith and Waitzman 1994) and education (Ross and Wu 1996) but also to their family network and social network. Though the mechanisms of such relations is not well explained, the association between personal network and health for elder is well documented in the literature of health for elders. The framework of this paper as illustrated in Figure 1 is designed to explore the relative effects of the individual family and social network on physical, mental and psychological health of older people and address the following two research questions:

1. Does the family network including relationships with close family members relate to the physical, mental and psychological health of older people?

2. Does the social network composed of relationships with friends, and distant relatives relate to the physical, mental and psychological health of older people?

In this study, we aim to explore the underlying relationships between the personal networks and their impact on physical, mental and psychological health of the aging population. In particular, we examine the impact of family network and social network on individual physical, mental, and psychological health for each surveyed country as well as at the macro level exploring aggregate level dataset. Focusing on the micro level, we cluster the data samples on individual demographic characteristics of age, sex, and locality of birth place. We then test the impact of family network and social network both together on each of physical, mental and psychological health of elder people using multiple linear regression method for each cluster.

Numerous researchers have followed Durkheim's (Durkheim 1979) lead in stating the importance of personal relationships with family and society such as marriage, parenthood, religious involvement, specific group or society membership on individual physical, mental and psychological health status, especially for the older people. There is substantial evidence in literature that social support and social participation lead to better health (Kaplan, Cassel et al. 1977; Gottlieb 1981; Goudy and Goudeau 1982; Berkman 1984; Kaplan and Hartwell 1987; Stevens 1992). Also, several researchers found that individuals who have a strong social connection and involvement live longer than socially isolated people (Berkman and Syme 1979; Funch and Mettlin 1982; Speigel and Bloom 1983; Goodwin, Hunt et al. 1987; Kawachi, Colditz et al. 1996; Zhang, Norris et al. 2007).

Social networks play an important role in the possession of good physical, mental, and psychological health for the elders. In a single nation study on 2603 adults randomly selected from among the members of a large health maintenance organisation, (Hibbard 1988) found that people who have more social ties engage in a greater number of health promoting and fewer risk-taking behaviors which are essential for sound health. This link is strongest among older people. Another study on the nationally representative Swedish study focusing on the data for the age group 77 to 98 years by (Lennartsson 1999) suggest that social contacts with friends are positively related to well-being or psychological health regardless of earlier health status. (Kawachi and Berkman 2001) revealed that there is a positive association between social ties and mental health. The study by (McAvay, Seeman et al. 1996) found that lower levels of social network contact were predictive of decline in health status. Most recently, (Heritage 2009) found the evidence of the association between weak social ties and poor health in his study on 5046 French adults with data about self-reported health. The association between social networks and health status is also examined in a cross-national study in the current literature. For example, in their cross-cultural study on older people from four Western Pacific nations, (Ferraro and Su 1999) found that psychological distress resulting from financial strain can be partially mitigated by social relationships. Considering a specific target group such as older people suffering a specific disease, the relation between social networks and health status is also tested. As for instance, a positive correlation is found between social support and lower risk of death in a study on older persons with diabetes (Zhang, Norris et al. 2007). This link was mediated by individual both physical and mental health status.

Research assessing the influence of family networks or ties on individual physical, mental, and psychological health argue that stronger family ties lead to better physical, mental and psychological health. In a study on 534 married parents between 68 and 73 years of age, (Ryan and Willits 2007) found that the quality of family ties positively correlated with self-rated physical and psychological health. There is evidence of the association between family ties and health status considering specific family relationship. As for example, (Mancini and Blieszner 1989) examined the influence of adult children on parental health and well-being by considering the presence and frequency of contact. They found that the more children there are and the closer they live to a parent, the higher levels of physical and psychological health for their parent. Simply having a grown child seems to enhance the health of elderly parents (Hughes 1989; Umberson and Gove 1989; McMullin and Marshall 1996). Moreover, research on family ties further suggest that having siblings may benefit the health of older persons (Cicirelli 1988; Scott 1990). For instance, the presence and frequency of contact with a sister is found to be a strong predictor of overall happiness among elderly women (O'Bryant 1988; Scott 1990). There is also some evidence found in present literature that the positive influence of a sibling on health and well-being may actually increase with age (Scott 1990; Campbell, Connidis et al. 1999).

From the review of the existing literature, we conclude that both social network and family network have influence on individual physical, mental and psychological health. Though most of the literature on social relations and individual health assessment comes from single nation studies (Hibbard 1988; Kawachi and Berkman 2001; Heritage 2009), there is presence of multi-national research suggesting similar outcome (Ferraro and Su 1999). Also, there are investigations which examine the influence of either social network or family network on a single (i.e. (Kawachi and Berkman 2001) or combination of any two (i.e. (Ryan and Willits 2007) of physical, mental, and psychological health. However, the presence of cross-national research considering the influence of both social network and family network on individual physical, mental and psychological health, all together, in current literature is lacking to date. In this study, we provide empirical analysis of the influence of both social and family network on individual physical, mental, and psychological health for four Eastern Mediterranean countries-- Bahrain, Egypt, Jordan, and Tunisia.

RESEARCH METHOD

The dataset entitled World Health Organisation Collaborative Study on Social and Health Aspects of Aging in Bahrain, Egypt, Jordan, and Tunisia, 1991 is located at the Inter-University Consortium for Political and Social Research (ICPSR) website. The life expectancy of people living in these four Eastern Mediterranean countries surveyed is increasing as with most western countries, leading to an increased proportion of people aged 60 and over in the total country population. Due to the deterioration of the inflammatory and immune response with age, elders need both proper health care service and support from family and community to fulfill their health-related needs for physical, mental and psychological health status. It could be therefore informative for decision makers to analyze the influence of personal networks on individual health status for elderly people of these four countries. The study was developed with the original purpose to perform a cross-national study of health and social status of the elderly. This study was investigated under the supervision of Professor Gary Andrews from Flinders University of South Australia, Australia.

2.1 Samples
This cross-national survey was conducted in 1991 and obtained interview responses from 4412 individuals, 799 from Bahrain, 1180 from Egypt, 1197 from Jordan, and 1236 from Tunisia. Though the survey considered only in-person social interactions without taking consideration of any social communication by modern technologies such as mobile and internet, its suitability for cross-national analysis of the association between individual network involvement and health status makes it unique for this study. The number of people of 60 years and over age group in the selected four countries surveyed ranged from almost 16,000 in Bahrain to over 3,000,000 in Egypt representing approximately 5 percent of each countries total population (Andrews 1991). Overall, 53.13 percent of survey individuals are male and 46.06 percent are female. And average age for the total survey population is 69.72 years. Table 1 describes the common statistics of the four surveyed nations.

Table 1: Common statistics on number of responses, sex, age and locality of living place of four surveyed countries.

The same questionnaire was used, a total of 401 questions, to sample older people of all four countries. Also, the samples of all four countries were designed to have nationally representative data by applying random sampling technique. Techniques were applied to ensure comprehension and validity of the response for any self assessed data. For example, to ensure that the self assessment of physical health status was a valid measure, this study asked an informant, someone who knew the respondent well, to rate the respondent's health. That informant was given the same choice of responses, as for the sample respondent, ranging from excellent to poor (Andrews 1991). On the whole, informant ratings agreed with self reported physical health rating by respondents. Moreover, to minimize the problems associated with cultural differences, the questionnaire for each country was translated into its own language and dialect, and then back-translated into English.
Data were gathered to provide information on the elderly in Bahrain, Egypt, Jordan, and Tunisia. Questions were asked regarding demographic characteristics (age, race, sex, marital status, religion, number of children and siblings, education), economic resources (employment status of respondent and of respondent's spouse, main income source, other income sources, whether house was owned), health (current health status, accidents and/or injuries affecting daily activities, number of times respondent saw a health professional in the previous month, number of days in hospital, nursing home, or rehabilitation center in the previous month, medications currently used, usage of any devices to assist in getting around), activities of daily living, living habits (smoking or drinking), social activities (club membership, whether respondent had a confidant), housing (satisfaction with current living conditions, accessibility to quarters, safety), and mental and psychological state of the respondent.

Though there are many similarities in cultural views, norms and attitudes towards social and family issues including family structure, women's role in family and society, and social stratification there are also differences in these four surveyed nations. Families are of mainly extended type in all four countries; however, in Egypt and Tunisia there is a growing tendency of nuclear family in urban areas. Nepotism is seen positively both in Bahrain and Egypt. Kinship and extended family ties play important role in developing social relationships in Egypt, Jordan and Tunisia. Women are more educated and publicly active in Bahrain than the other three countries. In Jordan, women are dependent on husbands. Their life is controlled by close male relatives in the absence of husband. Family background and wealth are very significant in defining individual social status.

2.2 Measures
The respondents were asked a number of questions that were related to the concepts under investigation: family network, social network, physical health, mental health, and psychological health. Multiple questions for each concept are used ranging from 3 for physical health to 8 for mental health to measure these concepts. A total of 8 questions (see Table 2) are used to measure individual family network. These questions are about the number of living sons and daughters, brothers and sisters that respondents have as well as number and frequency of their visit to respondent living place. To measure individual social network, 5 questions are considered based on individual membership and regular participation in meeting to any social group, relationship with friends and relatives (see Table 3).

Table 2: Questions used to measure Family Network Index (FNI)

Table 3: Questions used to measure Social Network (SNI)

It has been well documented in the literature that self assessment is a good indicator of individual actual physical status (Andrews, 1991). Also, in this study an informant was employed to assess individual physical health and then make comparison between the self assessment by respondent and assessment by informant. Overall, informant rating complies with the self assessment of individual physical health. Respondents were asked three questions (see Table 4) based on their personal opinion against their present physical health status. A total of eight questions were asked to the respondents regarding their common sense in making judgment and decisions, personality, behavioural attitude, memorizing power, depression, capability of interaction with others and ability to cope with normal stress of life in order to measure individual mental health status (see Table 5). The study asked five questions to assess respondent psychological health ranging from whether the respondents lost interest in doing things that they usually care about or enjoyed, to questions regarding their difficulty with sleep (see Table 6).

Table 4: Questions used to measure Physical Health

Table 5: Questions used to measure Mental Health

Table 6: Questions used to measure Psychological Health

There are some respondents who did not answer all the questions required to measure all the variables of our research framework (see Figure 1). In such situations, if there are answers of more than half questions for any variable, we measure it from those answers; otherwise, consider that variable for that particular respondent as a missing value. For instance, there are ten questions to measure individual mental health. For a particular respondent, if there are at least six answers out of ten answers available, then we measure mental health for that respondent from those six answers; otherwise, ignore it as missing value.

Figure 1: Framework of our research

As described in our research framework (see Figure 1), we used five continuous variables: two independent variables and three dependent variables in this study. The independent variables are family network and social network, and the dependent variables are physical health, mental health and psychological health. All of these variables are measured using questions asked of the respondent ranging from three for physical health to eight for mental health. An examination of the family network and social network measures in Microsoft Excel reveals common distributions of both of them that follow a non-normal curve. Each graph consists of a centralized score having a tapered skew to the left. These distributions are against a line indicating a non-normal and non-parametric statistical test is needed to be carried out in order to test their correlation with the dependent variables of our framework. The Spearman test is a non-parametric alternative to the Pearson test which investigates the relationships between two continuous scores.

2.3 Data Preparation
A 2-phase method for data preparation and analysis is used to examine the effects of individual personal network on different aspects of health status. The first phase included importing the data files into Microsoft Excel by placing the data into columns of Microsoft Excel representing questionnaire responses. Once the data is set up correctly, variables were cleaned and invalid responses such as refusals were removed in order to prevent inaccurate statistical testing. Since some questions like "How often do you go out to visit relatives?" had constructed numeric responses in reverse order "1 for daily, 2 for weekly, 3 for greater than weekly and less than monthly, 4 for monthly but less than quarter yearly, 5 for in six months, 6 for in more than in six month but less than one year, and 7 for once per year", where 1 represent the highest score and 7 represent lowest score, an inverse of the scores were taken so that any statistical analysis such as correlations, if carried out, would be able to give an accurate result. In the second and final phase, all the variables are placed into SPSS to perform some statistical analyses for testing the relationship between network involvement and health status.

RESULTS

We examined the effects of independent variables of family network and social network on dependent variables of individual physical, mental and psychological health status for elders both at macro and micro level. At micro level we seek the impact of both social network and family network on different aspects of health for different clusters of samples of all four surveyed nations based on demographic characteristics of sex, age, and locality of living place by applying multiple linear regression technique for the model in Figure 2. A significant disparity is found in morale score, ability of doing daily life activities and percentage of receiving health care services for different groups based on sex, age, locality of living place which guide us to choose these factors for clustering our data. Women show high morale score, which is based on attitude on own aging, agitation and loneliness, than men for all surveyed countries. There is an expected decline with age found in the surveyed population who can do all physical activities of daily life without help. Urban people have a high rate of receiving health care services from doctors than the rural people in Bahrain, Egypt and Tunisia; whereas in Jordan, the majority of rural people are unable to obtain their required treatment or care.

Figure 2: Multiple linear regression model to seek the impact of FNI and SNI on different aspects of health for elderly people in the surveyed countries.

3.1 Macro Level Analysis
We examined the relationships between independent variables and dependent variables for each country individually at macro level analysis. The coefficients values, as represented in Table 7, indicate a positive association between any combination of independent variables and dependent variables of our research framework for all countries. All the correlation coefficient values are significant at the 0.001 level. Because of larger sample size (minimum 799 for Bahrain) a small correlation coefficient value (lowest 0,062, between FNI and psychological health for Tunisia) shows significant statistical relation between the corresponding independent and dependent variables. SNI is found showing higher positive relationships than FNI with physical, mental and psychological health of elderly people for all surveyed nations (Table 7). The largest correlation coefficient (0.269) is found between SNI and mental health for Jordan.

Table 7: Correlation coefficients values between dependent and independent variables of our research framework for each of our surveyed country

3.2 Micro Level Analysis
In total, there are six clusters considered for multiple linear regression analysis at micro level; male and female for sex, urban and rural for locality of living place, and for age first cluster or group is from 60 to less than average age and range for second cluster or group is from average age to maximum age for the country under consideration. For example, for Bahrain the average age for all respondents is found to be 70.41 years and the maximum individual age is 130 years. As individual age is given in years without any fraction in the original dataset, the range for first cluster considering individual age is 60 to less than 70.41 years i.e. 60 to 70 years and for second cluster is 70.41 to 130 years i.e. 71 to 130 years. The ? and part-correlation values for all models in Figure 3 are illustrated in Table 8.

Table 8: Part correlation or semi-partial correlation values of multiple linear regression analysis of the three models as in figure 2 for the clusters based on sex, age, and locality of living place of the surveyed people.

Few of the part-correlation values show positive and significant (at 0.001 level) associations between corresponding independent and dependent variables of our research framework. Though the part-correlation values at Table 8 look like being scattered in different cells having the range of between -1 and +1, a further investigation to only significant part-correlation values reveals the following research findings:

(i) The part-correlation value for the association between SNI and psychological health is higher than the association between FNI and psychological health for the people who are younger than the average surveyed people age for all four countries.

(ii) Urban people show larger positive part-correlation to SNI than FNI with physical health for all four surveyed nations.

(iii) The part-correlation value for the association between SNI and physical health is higher than the association between FNI and physical health for the people who are older than the average surveyed people age for all four countries.

(iv) For male cluster, the part-correlation between SNI and mental health is larger than the part-correlation between FNI and mental health for all four countries.

(v) The part-correlation between SNI and physical health is higher for urban people than that of rural people for all countries.

(vi) For female cluster, the part-correlation between SNI and physical health is larger than that of male people for four surveyed countries.

DISCUSSION AND CONCLUSION

Our findings at macro level suggest that social networks have a higher association with individual physical, mental and psychological conditions than the family networks for all four surveyed countries. The multiple linear regression analysis at micro level illustrates the effect of both social network and family network, both together, on individual physical, mental and psychological health status. Though this analysis does not show significant result for all combination of social network or family network with physical, mental and psychological health for six clusters of surveyed data, it reveals some common pattern of associations between independent variables and the dependent variable of our research framework.

This research was designed to contribute to our understanding of how family network and social network influence the physical, mental, and psychological health assessment of elderly men and women. The two major aims identified were to examine (i) how family network and social network affect the health assessment of elders, and (ii) whether these relationships vary cross-culturally or there is a common pattern of relationships among surveyed nations.

In collecting survey data two types of questioning techniques, direct approach and indirect approach, were employed to ask respondents for their responses. For our research purpose of measuring variables from a total of 401 questions, we chose 34 survey questions which were designed by following the techniques of both direct questioning approach and indirect questioning approach. If a question like "How would you rate your health at present time?" is used for measuring physical health status, then it is a way of direct questioning approach. Example of indirect questioning approach is to use a question like "Have you lost interest in doing things you usually cared about or enjoyed?" for measuring respondent psychological health status. Though which types of questioning technique need to be applied depends on the type of questions being asked to respondents for their responses there is evidence in current literature suggesting more suitability to indirect questioning approach. According to (Fisher 1993), indirect questioning technique has been applied in surveys to reduce social desirability bias such as systematic error in self-report measures resulting from the desire of respondents to avoid embarrassment and project a familiar image to others. (Huntington, Mensch et al. 1996) found higher response rate for surveys if indirect questioning techniques employed. On the other hand, a study by (Bennett 1984) found that direct questioning technique is capable of providing a clear understanding of questioning purposes to respondents though it might be subject to a problem of response bias.

Additional research on the effects of family network and social network on physical, mental, and psychological health of elderly men and women is needed. The sample used in the current analysis is found homogeneous with regard to age, sex, and locality of living place such as urban or rural and was similar with respect to the level of education. Limited variations in these demographic and personal characteristics meant that information about important subpopulation was excluded. In addition, the applicability of the findings of this study needs to be explored for some small groups such as divorced or widowed participants, those who are childless, those who are physically disable, and those who are members of other racial or ethnic groups.

There is emerging unconventional social and family patterns which need to be focused with great importance in future research. This is because, those unconventional family and social patterns may play different implications than the traditional approach to family and social life on the physical, mental, and psychological health for elders. More recent cohorts are less likely to follow the traditional route through the life course and are more likely to divorce, bear fewer children, and have children outside of marriages. Also, there is a growing acceptance of gay and lesbian in many western societies; thus developing different pattern of social interactions (Shippy, Cantor et al. 2004). How these emerging patterns affect the pattern of family network and social network in later life for both men and women is not known yet.

This research is not without its limitations. Firstly, though the implications of people family network and social network on their different aspects of health for elder men and women are shown in this study, it did not explain the mechanisms of these implications. Secondly, the importance of the quality of family and social relationships are underscored in this research. For example, there are eight questions used to measure family network; however, no question identifies the depth of individual relationship with his/ her family network. Thirdly, the analysis did not examine the possibility of reciprocal linkages between individual two types of personal network and three health assessments for physical, mental and psychological health. Although the findings suggest that individual personal network have a positive effect on different health assessments, it is also possible that better physical, mental, and psychological health lead to stronger family and social participation. However, this kind of test for such interpretations is not generally feasible with cross-national data (Su and Ferraro 1997). Finally, to measure individual physical health, this study used self-reported data which may introduce misclassification bias to the study.

Despite these limitations, this is the first study in which we distinguish family network and social network of individual personal network, and examine the impact of these two networks on different health assessment of physical, mental and psychological health status for elderly people in a cross-national framework. Moreover, we use composite measure for research variables both for dependent and independent variables by applying responses of more than one question which reduce personal misunderstanding bias in case of use single question to measure research variables. Findings from this research might play an important role in developing health promoting programs for elders.

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