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PII: S0167-4943(18)30112-2
DOI: https://doi.org/10.1016/j.archger.2018.05.023
Reference: AGG 3687
Please cite this article as: Micheli K, Ratsika N, Vozikaki M, Chlouverakis G, Philalithis
A, Family ties and functional limitation in the elderly: Results from the Survey of Health
Ageing and Retirement in Europe (SHARE), Archives of Gerontology and Geriatrics
(2018), https://doi.org/10.1016/j.archger.2018.05.023
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FAMILY TIES AND FUNCTIONAL LIMITATION
Family ties and functional limitation in the elderly: Results from the Survey of
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Katerina Micheli MPH1m, Nikoleta Ratsika PhD2, Maria Vozikaki MPH1,
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Gregory Chlouverakis PhD1, Anastas Philalithis PhD1
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Department of social Medicine, Faculty of Medicine, University of Crete, Greece
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Department of Social Work, T.E.I of Crete, Greece
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Corresponding author: Katerina Micheli, E-mail addresskaterinamicheli@yahoo.gr
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Author Information
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Katerina Micheli planned the study, participated in the data analysis including the
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Ratsika Nikoleta contributed to the planning of the study and helped to revise the
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paper
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Highlights
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factors
limitation.
Persons that live alone did not show worse functional status,
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Southern and Mediterranean countries have both closer family ties and
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Abstract
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Objectives: To examine if family ties are strong predictors of functional limitation in
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older adults in Europe.
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Methods: Cross sectional data were used and included 14 European countries from
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the second wave (w2) of the survey on Health, Ageing, and Retirement in Europe.
13,974 adults aged 50+ (45.2% males and 54.8%females) were included in the study.
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Functional limitation was assessed using activities of daily living (ADL), instrumental
activities of daily living (i-ADL) and mobility sensory index. Family ties were based
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Results: Functional limitation was associated with females, age, self-rated health, and
symptoms but not with few family ties. After controlling for potential confounders,
respondents with lower family contacts showed higher risk for functional limitation.
Southern and Mediterranean countries have both closer family ties and adults with
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factors as well as little contact with family members. Further longitudinal research is
required in order to determine the association and the causal relationship between
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Introduction
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Elderly people aged 65 years or over constitute the highest proportion of the
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population in Europe. According to the baseline projection of Eurostat, the percentage
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of elderly people in Europe will increase by more than 28% in the year 2050 (Börsch-
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Supan et al, 2005). Rising longevity and declining fertility are reflected in a major
Commission 2014; Lee 2003). Moreover living arrangements of older adults have
changed dramatically over time (Tomassini 2004). The demographic transition and
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changes in the economy have important implications for family structure and as a
consequence it is unclear how people related to each other (Cherlin 2010; Lee 2003).
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way of life. Thus, estimating elderly health involves the assessment of both their
restrictions in performing fundamental physical and mental actions used in daily life
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(Guralnik et al 1996; Stuck 1999). Hence the ability of societies to continue to meet
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the needs of their oldest members may be increasingly challenged by an increase in
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the rates of physical impairment due to advanced aging (Litwin et al 2012). However,
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it has been noted that such a decline in health may not be inevitable and is certainly
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not experienced equally by all older adults (Seeman 2002).
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A major challenge for health workers is the reduction of functional limitation.
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Understanding the factors that contribute to functional limitation may help all the
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elderly health care workers in the development of efficient preventive strategies.
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Several studies have addressed the risk factors for functional decline, which were
mass index, health related behaviors such as drinking and smoking, demographical
factors, family and social contacts, cognitive impairment, depression and stress (Stuck
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1999).
support and family ties are among the factors which are known to have a beneficial
However, there are relatively few studies on the effects of family support on
living alone or living with children or non spousal family members predicts functional
decline (Saito et al 2017; Saito et al 2014; Wang et al 2013; Wang et al 2009; Spalter
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2008). Moreover other aspects of family support such as frequency of contacts, and
family ties have been associated with development of functional decline (Murata 2017
Leon et al 1999). However, in some other studies, social and family ties did not seem
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et al 1995). Social and family networks are associated with functional ability in a
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protective way. These protective effects of social networks may come as a result of
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several supportive processes that include providing health-related information,
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encouraging healthy behaviors, health care utilization, providing emotional support so
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as to facilitate coping with life stress, enhancing feelings of self-esteem and control as
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well as affecting neuroendocrine or immune functioning (Unger et al 1999; Seeman et
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al 1996).
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Strong family and social ties may promote emotional, financial or practical
support leading to several positive health outcomes (Mair 2013). The sole presence of
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family is an important indicator of positive health outcomes, even if family ties do not
2016; Mair 2013). The disablement process of functional limitation has various
biological and social factors. Therefore, gaining insight into which factors have a
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greater impact on the functional capacity of the elderly is, indeed, a matter of great
interest.
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To the best of our knowledge, this is the first study which examines a wide
limitation in a representative sample of adults aged 50 years and over. The purpose of
the present study is to determine the associations of family ties and functional
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parameters. The study examines the following hypotheses: i) few family ties are
associated with functional limitations; ii) Functional limitations are mostly associated
with few family ties rather than socio-demographic factors such as gender, age,
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education, income, etc, or biological factors, such as co-morbidity; and iii) Evidence
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of regional variations with regard to the association of family ties and functional
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limitations.
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Methods
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For the purpose of the present study, data were drawn from the second wave
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(w2) of the Survey of Health, Ageing and Retirement in Europe (SHARE), carried out
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during 2006-2007. Data for the second wave included information of 14 European
Switzerland, Austria, Italy, Spain, Greece, Ireland, Poland, and the Czech Republic).
relationships of individuals aged >50 years. The survey has been organized and
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(Borch-Supan 2005).
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The targeted population of the survey consisted of households with at least one
individual aged 50 and over who was a resident of that country and spoke the
did not reside at the sample address at the time of the survey, were physically or
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mentally unable to participate, or could not speak the language of the national
questionnaire. The studied population was selected in each country according to the
(including sampling procedures. recruitment rates. ethical issues etc.) has been
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Because the focus of the present study was mainly on the more intimate family
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ties, the sample was restricted to people aged 50 years and over with children.
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Moreover, people with dementia were excluded from the analysis. In total, 13,974
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adults were eligible for inclusion in the present analysis.
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Data Collection
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The main survey data was collected using computer-assisted personal
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characteristics, physical and mental health, social activities, behavioral risks, social
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support, cognitive function, health care, household income etc. In order to investigate
more sensitive questions, the interviews were further completed by a brief self-
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Measures
(Nikolas et al 2003; Lawton et al 1969). The present study also sought to estimate the
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functional limitation index by adding the 13 limitations registered in the ADL and i-
ADL scales and the 10 self-reported questions of mobility limitation, thus giving a
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Family ties:
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In determining family ties, variables of family structures were included. i)
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marital status (living alone vs living with spouse /partner); ii) number of children; iii)
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frequency of family contact over the last 12 months; iv) family spatial proximity.
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The categories of contact with family members were defined as: about once a month
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or less or never, about once a week or every two weeks, several times a week, daily.
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The second indicator was based on the reported spatial density of the family network.
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The categories of family spatial proximity were defined as: low spatial proximity
between 100 and 500 kilometers, moderate spatial proximity between 25 and 100
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kilometers, high spatial proximity between 5 and 25 kilometers and very high
A total ‘family ties’ index was estimated by summing up the scores of each
indicator. The score ranges from 0 to 9, with higher scores indicating higher levels of
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family ties.
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Additional Measures
retirement status, European region (north, central, south) and income. Income was
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classified using country specific quartiles for all participants in SHARE, while years
of education were calculated using the total time of study at various levels of
health and mental health. To assess chronic conditions, participants were asked if a
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well as other conditions). To assess the number of symptoms experienced,
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participants were asked if they had had any of the 11 symptoms (e.g falls. dizziness.
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stomach problems and other) over a period of six months prior to the date of the
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interview. Responses for both medically diagnosed chronic conditions and self-
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reported symptoms were divided into three categories 1- zero 2- one or two, 3-three or
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more. Self-rated health was assessed by having participants report their health as
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excellent, very good, good, fair and poor. Mental health status was measured by the
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Statistical analysis
Data were analyzed using the SPSS software (IBM SPSS Statistics for
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Windows. Version 230. Armonk. NY: IBM Corp) and Stata/MP 3.1. Weights were
applied reflecting non responses and stratification design according to the complex
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sampling design of the study. The prevalence and corresponding 95% Confidence
Intervals (95% C.I) of the components of family ties and functional limitations were
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the association between functional limitations, family ties and the other variables. In
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the first model, we examined the association between functional limitations and all
the significant health demographics and family ties factors. All the factors were tested
between function limitations and each family factor, including potential confounders.
Adjusted ORs were estimated separately for each family factor. 95% CIs were
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score of family ties and index of functional limitations were graphically illustrated.
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Results
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Baseline characteristics of the study sample are shown in table 1. The sample
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had a majority of women (54.8%), while the mean age of the whole sample was 66.6
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years. Average education was 8-12 years. A greater percentage of participants
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expressed fair or poor self-rated health (36.9%). A significant part of the overall
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retired and lived in central Europe. According to the Index of Functional Limitations,
functional limitations.
Table 2 presents the score of family ties in the study sample. The mean value
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of family ties was 5.98. Almost half of the sample participants reported having more
than 2 children and high proximity to the family network. Additionally, a relatively
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limitations and the components of family ties. The prevalence of participants with 3 or
more functional limitations was significantly higher among those who live alone
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(54.9% p<0.001) and reported 2 or more children. As regards family ties, participants
who reported functional limitations lived within close distance of the whole family
and had daily contact with the rest of the family members.
functional limitations and all the covariates are presented. Females (OR 1.76 95% CI
1.43-2.17), age (OR 1.72 95%C.I 1.54—1.93), self rated health (OR 2.85 95%C.I
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2.45-3.32), chronic diseases (OR 1.46 95%C.I 1.30-1.65), disease symptoms (OR
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3.29 95%C.I 2.92-3.71), and depressive symptoms (OR 1.93 95%C.I 1.70-2.22),
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showed significantly greater risk of functional limitation. There is no association
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between few family ties and higher functional limitations.
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Table 5 presents the association between each family type and functional
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limitation after adjusting for potential confounders. Few family contact shows greater
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risk for functional limitations after adjusting for potential confounders (OR 1.58 95%
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Figure 1 illustrates the mean levels of family ties and functional limitations
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among thirteen European populations. Countries with higher family ties have higher
regions show significally higher rates of family ties and a higher score of functional
Discussion
Understanding the factors that are accountable for functional limitation can
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of signs indicating that elderly people are at risk of losing their autonomy, as well as
the implementation of an assessment coping strategy could prevent or delay the onset
provide us with vital insight into the social and family profile of the elderly. The aim
of this cross sectional study was to determine whether the burden of functional
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health problems or whether it can also be attributed to the presence of other
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psychosocial parameters in the European study sample of the SHARE study.
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Furthermore, the prevalence of functional limitation and the kind of family relations
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were measured, in the European Study sample of the SHARE study.
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Initially, an effort was made to associate functional limitation with all the
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predisposing factors of the study. With regard to our main hypothesis, the results of
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our primary regression analysis provide no evidence that few family ties are
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terms of family closeness and social contacts without taking into consideration the
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indicates that the family tends to “keep” the functionally- limited elderly within close
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proximity irrespective of the quality of their relations. In this study, the focus is on
family ties, in terms of family structure, family contact and family spatial proximity
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as well as the potential risk factors for instrumental functional disability, excluding
models that examine cognitive function, although other studies analyze the
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demographic factors, our findings are consistent with similar findings of the
international literature (Pope et al 2001; Jenkins 2004). As for the influence of family
or social ties on functional ability, the results in comparison to the literature are
family ties in terms of closeness and frequency of contact have been identified as a
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protective factor for functional decline (Murata et al 2017; Zunzunequi et al 2005;
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Strawbridge et al 1996; Mendes de Leon et al 1999; Unger et al 1993; Seeman et al
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1996;). However, these results are contradictory to our study. While other studies
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demonstrate no significant association to the burden of functional limitation
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(Strawbridge et al 1993; Liu et al 1995), their findings are consistent with the results
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of our study. It was difficult to compare our findings with other studies due to many
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factors such as: i) different sample size and nature of the study sample. ii) different
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measures and definitions of social or family relations iii) in prospective studies, the
intervals over which the changes are examined vary iv) age differences among subject
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samples in most studies. Moreover, the design of the current study is cross sectional,
ties, we found that the factor of low family contact constitutes a great risk for
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consistent with relatively similar findings of the literature, indicating that instrumental
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or emotional support, loneliness and close family ties affect functionality. (Murata et
Unger et al 1993; Mendez de Leon et al 2001). One possible explanation for the worst
functioning profile of the elderly could be the feeling of losing support and, as a
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consequence, the negative effect of feeling alone and helpless. It has been previously
mentioned in the literature that relationships in general, including social and family
According to the results of our research, persons that live alone did not show
worse functional status, these findings being consistent with previous studies (Wang
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et al 2013; Wang et al 2009). One possible explanation for this situation could be that
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functional disability may facilitate cohabitation. In other words, the elderly would
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tend to cohabit in the absence of functional ability. On the contrary, other studies,
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mostly in men, have shown a higher risk of functional disability in older adults living
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alone (Saito et al 2017; Lund et al 2010; Nilsson et al 2008). This disagreement
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between the findings could be explained by the degree of social satisfaction of the
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elderly, higher satisfaction reducing the risk of disability (Lund et al 2010). However
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further investigation is needed in order to explain the cohabitation status risk in the
In an attempt to better understand the role of family ties and their potential
influence on functional ability we should take into account the consequences of the
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relatives in order to look for a better job. Moreover, as mortality rates decline, people
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may suffer from more diseases. As a consequence, they need more care and help.
Also, as fertility declines, the number of older children available to help frail parents
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is reduced, as well as the overall size of kin networks (Sear and Coall 2011).
age growth and the altered structure of the family, may lead to a greater degree of
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complexity in family life. The changes in family patterns in recent decades complicate
the way that people view their obligations to each other (Cherlin2010).
disability and family relations separately for each of the European countries of the
Poland, show higher rates of dysfunction and simultaneously higher rates of family
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ties. On the contrary, countries of northern and central Europe seem to have a lower
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mean score of family ties and lower rates of dysfunction. Cultural differences may
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partly explain the prevalence of differentiations within the European countries. Each
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country may interpret the meaning for the burden of functional disability and family
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ties in a different way. In northern Europe, autonomy and independent living are
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considered to be quite high, which explains the few family ties despite the burden of
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limitations. On the contrary, in southern countries, assisting family members is
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countries place more emphasis on the social care system which promotes independent
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living.
Our study has some limitations. Firstly, the design of the study is cross
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this reason, conducting a longitudinal study in the future, or analyzing changes over
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time, to examine the association between family ties and functional capacity is
bias in the measurement method. However, using self-reported data in large scale
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Furthermore, the data in our study is from the period 2006-2007, since data is not
available from all the participating countries in successive waves of the study. For
instance, Greece did not participate in waves 4 and 5 of SHARE, because of the fiscal
crisis. However, the longitudinal design of SHARE allows for future research in order
to examine the changes in association between family ties and functional disability.
Comparisons between waves might yield evidence to explain the association between
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low family ties and functional limitations, to understand the complex underlying
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process, and to explain the magnitude of these effects over time. In addition, it would
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be interesting to evaluate the association between family ties and functional disability
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across Europe. Finally, the current study excludes adults without children and
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consequently a full representation of family deficiencies pertaining to all the subjects
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of the study is not feasible. Strengths of the present study include the large sample
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size of the study which could be considered as representative of the general
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population. Moreover, the exclusion of adults with dementia reduced the likelihood of
Conclusions
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The present study provides evidence that risk in functionality is higher due to
strategies for disability, health professionals should take family relations into account.
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functional limitation and family ties and to better understand the complex underlying
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processes. This finding may indicate that this correlation may be more complicated,
and a model of causal relationship is needed in order to prove the reliability of the
results. Nevertheless, the cross sectional design of the current study cannot detect
Conflicts of interest
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None
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Acknowledgments
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This research study uses data from SHARE project release 2.3.0. SHARE data
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collection in 2004-2007 was primarily funded by the European Commission through
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its 5th and 6th framework programmes (project numbers QLK6-CT-2001- 00360;
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RII-CT- 2006-062193; CIT5-CT-2005-028857). Additional funding by the US
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P01 AG08291; P30 AG12815; Y1-AG-4553- 01; OGHA 04-064; R21 AG025169).
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a full list of funding institutions). The SHARE data set is introduced in Borsch-
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47. Wang, H., Chen, K., Pan, Y., Jing, F, Liu, H. (2013). Associations and Impact
48. Wang, H., Zheng, J., Kurosawa, M., Inaba, Y., Kato, N. (2009). Changes in
T
activities of Daily living (ADL) among elderly Chinese by Marital status,
IP
living arrangement, and availability of healthcare over a 3-year period.
R
Environmental Health and Preventive Medicine, 14,128-141
SC
49. Zunzunegui, M. V., Rodriguez-Laso, A., Otero, A., Pluijm, S.M.F, Nikula, S.,
U
Blumstein, T., Jylha, M., Minicuci, N., Deeg, D. J. H. (2005). Disability and
N
social ties: comparative findings of the CLESA study. European Journal of
A
Ageing, 2, 40-47
M
Figure legend
ED
Fig 1. Mean levels of Composite Score of Family Ties and index of Functional
PT
Limitations in the sample of 13.974 European adults, aged 50+ years, among thirteen
24
FAMILY TIES AND FUNCTIONAL LIMITATION
T
R IP
SC
U
N
A
Τable 1. Descriptive characteristics of 13.974 adults, aged 50+ years in the SHARE
M
n %
Education
0-7 4.035 28.9
(years)
8-12 6.351 45.5
13+ 3.573 25.6
mean ± standard deviation (min-max) 9.8±4.5 (0-25)
Self-rated health Fair, poor 5.150 36.9
25
FAMILY TIES AND FUNCTIONAL LIMITATION
a
Chronic diseases 3+ 3.241 23.2
Disease symptoms 3+ 3.932 28.1
European Depression Scale Score 4+ 3.496 25.3
Retirement status Retired 8.069 58.0
European region North 2.736 19.6
Central 8.587 61.4
South 2.651 19.0
Income b Lower quartile 3.236 23.2
T
Index of Functional Limitations c None limitation 6.695 47.9
IP
1 1.934 13.8
2 1.349 9.7
R
3+ 3.996 28.6
a
exclusion of people with alzheimer's disease, dementia and senility.
SC
b
Income was classified using country-specific quartiles for all participants in
SHARE survey in 2006/07.
c
U
Index was estimated by adding up 13 limitations [as Activities of Daily
N
Living (ADL) and instrumental activities of daily living - (I)ADL] with 10 mobility
A
dysfunctions and giving a composite score from 0 to 23
M
Table 2. Indexes and Score of Family Ties in the sample of 13.974 European adults,
ED
weight Estimated
Indexes and score of family ties Scoring n 95% CI
PT
% population
26
FAMILY TIES AND FUNCTIONAL LIMITATION
T
or never
contact
IP
About once a week or every
index 1 2.664 18.9 17.6. 20.2 10.265.903
two weeks
R
Several times a week 2 4.912 31.2 29.7. 32.8 16.974.764
SC
Daily 3 5.691 44.1 41.6. 46.5 23.947.975
Composite Score
of Family Ties a
mean (95% CI)
U
5.98 (5.90. 6.06)
N
95% CI: 95% confidence intervals. C.I estimated through the complex sample
A
design procedure.
a
The Composite Score of Family Ties ranges from 0 to 9, according to scoring
M
27
FAMILY TIES AND FUNCTIONAL LIMITATION
0-2 limitations 3+
p-value
Indexes and Score of Family Ties weight % (n)
a
T
<0.001
IP
With spouse. partner 64.0 (6.996) 45.1(2.107)
R
2 44.9 (4.560) 36.2 (1.570) <0.001
SC
3+ 36.4 (3.747) 44.7 (1.683)
Family Low proximity (between 100 -500 km) 10.3 (868) 6.1 (247)
Proximity U
N
Moderate proximity (between 25-100 km) 9.4 (957) 6.9 (303)
index <0.001
A
high proximity (between 5-25 km) 48.2 (5.430) 51.5 (2.219)
M
Family About once a month or less or never 5.5 (470) 6.4 (237)
contact About once a week or every two weeks 19.8 (1.989) 17.0 (675)
PT
<0.001
index Several times a week 33.3 (3.705) 26.9 (1.207)
E
Composite Score of Family Ties b <25th percentile 71.4 (1.859) 28.6 (728)
a
Tests of independence (based of adjusted-F). They were estimated through the
complex sample design procedure.
b
Composite Score of Family Ties: <25th percentile (score <5) indicates few family
ties >75th percentile (score >7) indicates higher family ties.
28
FAMILY TIES AND FUNCTIONAL LIMITATION
aged 50+ years in the SHARE study (wave II. 2006/07). in relation to categories of
Index of Functional
Limitationsa
T
(95%CIs)c
IP
Gender (females vs males) 1.76 (1.43. 2.17)
R
Age (by one category of years) 1.72 (1.54. 1.93)
SC
Education (by one category of years) 0.75 (0.67. 0.83)
European Depression Scale (score 4+vs score <4) 1.93 (1.70. 2.22)
European region (across to north. central and south countries) 1.03 (0.88. 1.21)
>75th reference
CC
29
FAMILY TIES AND FUNCTIONAL LIMITATION
Τable 5. Adjusted ORs of Index of Functional Limitations in 13.974 adults, aged 50+
years in the SHARE study (wave II. 2006/07), in relation to categories of indexes
Index of Functional
Limitationsa
T
Indexes and Score of Family Ties
(95%CIs)c
IP
Living status alone 0.95 (0.82. 1.11)
R
with spouse. partner reference
SC
Children 1 1.01 (0.82. 1.24)
3+
U reference
N
Family proximity Low proximity (between 100 -500 km) 0.69 (0.46. 1.03)
A
index Moderate proximity (between 25-100 km) 0.82 (0.58. 1.17)
M
house)
Family contact About once a month or less or never 1.58 (1.13. 2.22)
PT
index About once a week or every two weeks 1.13 (0.86. 0.48)
Daily reference
CC
a
Index was estimated by adding up 13 limitations [as ADL and - (I)ADL] with 10
mobility dysfunctions and giving a composite score from 0 to 23.
A
b
In relation to having 0-2 limitations.
c
95%CIs. 95% confidence intervals.
Multiple logistic regression analysis (estimations according to the complex sampling
design of the study). As covariates were used the gender, age, education status, self-
rated health status, chronic diseases, disease symptoms, European Depression Scale
score, retirement status, European regions and income levels.
30
FAMILY TIES AND FUNCTIONAL LIMITATION
T
RIP
SC
U
N
A
M
ED
E PT
CC
A
31