Ageing Int (2010) 35:38–60

DOI 10.1007/s12126-009-9050-7

Contributions of Psychological Well-Being and Social

Support to an Integrative Model of Subjective Health
in Later Adulthood

Sophie Guindon & Philippe Cappeliez

Published online: 14 January 2010

# Springer Science+Business Media, LLC 2010

Abstract This study examined the contributions of psychological well-being and social
support to an integrative model of subjective health among older adults. Structural
equation modeling was used to test the proposed model of subjective health which
included age, education, physical health problems, functional status, psychological well-
being and social support. Partial support for the model was found. Psychological well-
being had both a direct effect on subjective health and an indirect effect mediated by
physical health problems. Social support had an indirect association with subjective
health via its effect on psychological well-being. Functional status had only a weak effect
on subjective health. Longitudinal data at a six-year interval revealed the same direct and/
or indirect effects of these variables on subjective health. This study sheds light on how
psychological and social resources are linked with subjective health in later adulthood.

Keywords Subjective health . Older adults . Psychological well-being . Social support

Older age is associated with an increase in chronic health problems and physical disability,
yet the majority of older adults evaluate their health in positive terms (e.g. Statistical
Report on the Health of Canadians 1999; Canadian Study of Health and Aging Working
Group 2001). Subjective health is of particular interest in gerontological research, as it
appears to predict important variables including functional decline (Grand et al. 1988;
Idler and Kasl 1995; Kaplan et al. 1993; Mor et al. 1994) and even mortality after other

The Canadian Study of Health and Aging (CSHA) was funded by the Seniors’ Independence Research
Program, through the National Health Research and Development Program (NHRDP) of Health Canada
(Project No. 6606-3954-MC[S]). Additional funding was provided by Pfizer Canada Incorporated through
the Medical Research Council/Pharmaceutical Manufacturers Association of Canada Health Activity
Program, the NHRDP (Project No. 6603-1417-302 [R]), Bayer Incorporated, and the British Columbia
Health Research Foundation (BCHRF Projects No. 38 [93-2] & No. 34 [96-1]). The CSHA was
coordinated through the University of Ottawa and the Division of Aging and Seniors, Health Canada. The
authors wish to express their appreciation to all staff across Canada involved in the CSHA.
S. Guindon : P. Cappeliez (*)
School of Psychology, University of Ottawa, Ottawa, ON, Canada
e-mail: Philippe.Cappeliez@uottawa.ca
Ageing Int (2010) 35:38–60 39

covariant factors including objective indicators of health are taken into account (for
reviews, see Benyamini and Idler 1999; Idler and Benyamini 1997). These observations
suggest that subjective health encompasses elements that are not necessarily captured by
objective measures of health and underlines the relevance of gaining a better
understanding of subjective health. In keeping with this objective, it appears important
to identify the principal determinants of subjective health, and in particular, those
variables which may affect subjective health positively in later adulthood.
Consistent with traditional biological and Western views of health, models of
subjective health have generally focused on physical health and functional status (e.g.
Johnson and Wolinsky 1993; Liang 1986). Subjective health in later adulthood is
indeed linked to physical health indicators such as number of reported health
problems (Pinquart 2001), medications used (Benyamini et al. 2000), as well as
functional disability (Bookwala et al. 2003; Lee and Shinkai 2003; Pinquart 2001).
Sociodemographic factors have also been included in many studies of the
determinants of subjective health. Review of the literature reveals that the relationship
between gender and the subjective health of older adults is still unclear (Gonzalez et
al. 2002; Henchoz et al. 2008; Saevareid et al. 2007; Prus and Gee 2003). In particular,
several studies have found that the predictors of subjective health may vary according
to gender (Heikkinen et al. 1997; Leinonen et al. 1999; Prager et al. 1999; Prus and
Gee 2003; Rodin and McAvay 1992; Schulz et al. 1994). The effect of age on
subjective health also varies from one study to the next. Results of two meta-analyses
that included cross-sectional (Roberts 1999) and longitudinal (Pinquart 2001) studies,
reveal a slight decrease in subjective health with increasing age, especially among
adults 80 years and older. However, these results are interpreted as the effect of
increasing health problems and functional limitations with age (Pinquart 2001), which
suggests that age probably does not exert a direct effect on subjective health, but rather
an indirect one through physical health and functional status. This hypothesis has
received some empirical support (Orfila et al. 2000). In addition, studies have shown
rather consistently that higher education is associated with better subjective health (e.g.
Grundy and Sloggett 2003; Murrell and Meeks 2002; Prus and Gee 2003; Von dem
Knesebeck et al. 2003; Zimmer and Amornsirisomboon 2001).
As Mossey (1995) pointed out, psychological variables can also influence
subjective health. She proposed a model of subjective health that includes mental
health as predictor of subjective health, alongside physical health, functional status,
and sociodemographic variables. This model proposes that sociodemographic
variables have a direct effect on subjective health, as well as indirect effects through
the three other variables. The model further posits that physical health exerts direct
and indirect effects through mental health and functional status, which in turn both
have direct effects on subjective health. Finally, in addition to its direct effect on
subjective health, mental health is hypothesized to have indirect effects via physical
health and functional status. Regrettably research simultaneously testing the
predictions of Mossey’s model is still lacking.
The criticism of tautological reasoning could be leveled against this approach to the
determinants of subjective health, as physical and mental health indicators can be
expected to share much variance with subjective health. However, closer examination
of these constructs and their measurements reveals that they are distinct. Specifically,
while more objective indicators of physical health (e.g. health problems checklist or
40 Ageing Int (2010) 35:38–60

medical antecedents) and functional status (e.g. ability to accomplish various activities
of daily living or level of mobility) may indeed influence self-assessment of health,
clearly the perception of one’s health transcends this information and indeed is
influenced by a variety of personal factors such as mood, self-perception/concept,
expectations, and comparisons with others, to name a few. Regarding psychological
well-being, typical indicators such as life satisfaction, happiness, self-esteem and
perception of control, are much broader and multi-facetted concepts than subjective
evaluation of health. At the empirical level also, items referring to perception of
physical health in typical measures of psychological well-being constitute only a very
small fraction of the dimensions assessed by such measures.
It is important to note that research on the psychological determinants of
subjective health has largely adopted a pathogenic perspective by conceptualizing
mental health in terms of level of psychological distress and thus focusing on factors
that undermine subjective health. Yet it has been reported that positive indicators of
psychological well-being such as life satisfaction (Lee and Shinkai 2003), perception
of control (Chipperfield et al. 2004), and self-esteem (Cairney 2000; Starr et al.
2003), are also associated with subjective health. In fact, emerging evidence suggests
that positive psychological functioning may represent an important long-term
predictor of subjective health (Benyamini et al. 2000). However, how these
psychological factors precisely relate to subjective health remains an open question.
While psychological well-being could directly influence self-evaluations of health, a
growing body of research suggests that objective indicators of physical health can also
be positively affected by various dimensions of psychological well-being, including
positive affect (Fredrickson and Levenson 1998; Ostir et al. 2001a; Ostir et al. 2004;
Ostir et al. 2001b; Xu 2006), perception of control (Chipperfield et al. 2004), and
healthy global psychological well-being (Keyes 2005). Notably, experimental
research has demonstrated that the induction of positive emotions restored
cardiovascular physiological activation induced by negative emotions or stress,
which suggests that mood can exert a direct effect on the risk of illness (Fredrickson
and Levenson 1998). Thus, it appears likely that psychological well-being could
indirectly affect subjective health through its effect on objective physical health.
Although findings have been inconsistent, there is also research pointing to the
relevance of social support. Overall, positive integration within diverse social
networks appears to be related to better subjective health (Wu and Rudkin 2000;
Zunzunegui et al. 2004), with emotional support seemingly the most beneficial for
subjective health (Zunzunegui et al. 2001). The positive effects of social support on
subjective health may well be mediated by psychological variables (Landau and
Litwin 2001; Okamoto and Tanaka 2004).
Despite the above-mentioned evidence, research on subjective health from a
salutogenic perspective, focusing on factors that promote health such as positive
psychological functioning and social support (Ryff and Singer 1998; Seligman and
Csikszentmihalyi 2000), has been lacking. Yet, considering the role of these
variables could help elucidate how older adults can maintain a favorable subjective
health despite an objective decline of physical health. Therefore, the main objective
of the present study was to examine how psychological well-being and social
support relate to subjective health among older adults. These relationships were
tested using the framework of an integrative model of subjective health that stems
Ageing Int (2010) 35:38–60 41

from Mossey’s model of subjective health (Mossey 1995). The proposed model
incorporates positive indicators of psychological well-being and social support as
predictors of subjective health.
On the basis of the literature reviewed above, and as Fig. 1 illustrates, the main
hypothesis was that psychological well-being, operationalized as general mental
health status, life satisfaction and positive psychological functioning, would have a
favorable direct effect on subjective health, as well as an indirect effect through
mediation by physical health problems and functional status. Given the less consistent
relationship between social support and subjective health, it was hypothesized that the
effect of social support would be a favorable but indirect one, mediated by
psychological well-being. The proposed model further posits the following subsidiary
hypotheses : 1) age would have an indirect unfavorable effect on subjective health,
mediated by physical health problems and functional status; 2) education would have
direct and indirect favorable effects on subjective health, the latter mediated by
physical health problems, functional status and psychological well-being; 3) physical
health problems would have direct and indirect unfavorable effects on subjective

err10 err9 err8

1 1 1
Mental Positive Life
Health Psych. Funct. Satisfaction

Social Psychological 1
res3
Support Well-Being
res4

1
Age
Subjective
Health

Education

1 Physical Functional 1
res1 Health res2
Status
Problems
1
1
Visual Auditory Illness Antece PADL IADL Mobility
Acuity Acuity dents

1 1 1 1 1 1 1

err1 err2 err3 err4 err5 err6 err7

Fig. 1 Proposed integrative model of subjective health

42 Ageing Int (2010) 35:38–60

health, the latter mediated by functional status and psychological well-being; and 4)
better functional status would have direct and indirect favorable effects on subjective
health, the latter mediated by psychological well-being.
The test of this model was first performed on cross-sectional data obtained from a
large representative sample of older adults. The predictive power of the resulting
model was further tested using longitudinal data from the same sample. Specifically, it
was hypothesized that the final model resulting from the cross-sectional analysis
would also significantly predict future subjective health. Since the research literature is
equivocal regarding gender differences in subjective health, analyses were performed
on men and women separately in order to elucidate potential gender differences.

Method

Participants

Data were obtained from the Canadian Study of Health and Aging (CSHA Working
Group 1994), a longitudinal investigation comprising a large nationally representa-
tive sample of adults over 64 years of age. A randomized sample of older adults was
created from government health records in all provinces except Ontario, where
enumeration records were used instead. The Yukon and North–West Territories were
excluded from the CSHA due to the small number of older adults inhabiting those
regions. Data collection for the CSHA was divided into three phases. A total of
9,008 community-dwelling older adults and 1,255 living in institution participated in
the first phase (CSHA-1) in 1991–1992. The latter underwent a clinical exam for
assessment of their cognitive functioning, while the former completed with a
qualified interviewer a standardized interview which included a cognitive screen, the
Modified Mini-Mental State Examination (3MS; Teng and Chui 1987). Those
presenting possible cognitive impairments were further assessed for dementia.
Community-dwelling participants who were deemed free of dementia in CSHA-1
were invited to participate in the second phase (CSHA-2) in 1996–1997. Among the
5,703 participants from CSHA-2 (63.3% of original sample), 5,395 lived in the
community whereas 308 moved to an institutional setting. Only the community-
dwelling sample from the CSHA-2 was retained for the present study, given that all
the measures of interest were administered to this sample at that time. Participants
from the CSHA-2 whose scores on the 3MS suggested possible cognitive problems
were excluded from the present study as they were not required to respond to all
measures in the interview, resulting in a total of 4,329 participants. Of this sample,
only the English-speaking participants were retained to increase sample homogeneity.
The resulting sample consisted in 3,599 participants (2,171 women, 1,428 men)
aged between 69 and 105 (M=78.58, SD=5.76). Half of the participants were
married (50.7%) and 39.8% were widowed. Participants completed an average of
11.39 years of education (range from 0 to 33; SD=3.45) and 49.3% reported an
annual household income below $30,000. On average, 4 physical health problems
were reported over the past year (range 0 to 13; SD=2.32). From this sample, a total
of 2,367 participants (1,471 women, 896 men) responded to the subjective health
measure in the CSHA-3, which took place in 2001–2002. The cross-sectional
Ageing Int (2010) 35:38–60 43

analyses in the current study are based on the data from CSHA-2, and the
longitudinal analyses use data collected in CSHA-2 to predict subjective health
assessed in CSHA-3. To simplify, CSHA-2 and CSHA-3 data are referred to
respectively as Time 1 and Time 2 data in the present study. More information on the
samples of CSHA-1 and CSHA-2 is available elsewhere (McDowell et al. 2001).

Measures

Sociodemographic variables They included gender, age, and years of education.

Subjective health Subjective health was assessed with the following question:
« How would you say your health is these days? (5 = very good, 4 = pretty good, 3 =
not too good, 2 = poor, 1 = very poor) ». Use of such a single global question is one of
the most frequent manner of measuring self-rated health, and it is considered as a
reliable measure of subjective health for older adults. Studies evaluating subjective
health with five response choices with older participants have reported good test-retest
reliability, using weighted Kappa statistic (in order to account for partial agreement
among ordered categories). Indeed, Andresen and colleagues reported a Kappa
coefficient of 0.67 for adults aged 65 years and older, over a 2-week interval (Andresen
et al. 2003). Crossley and Kennedy (2002) indicated a Kappa coefficient of 0.69 for
adults aged 70 and over, for an evaluation performed before and after another set of
health related questions. Furthermore, criterion validity for such a measure is
supported by the demonstration of significant graded relationships with health events
in adults of middle and older ages (Wurm et al. 2008).

Physical health problems Physical health problems were assessed with four
measures. The first comprised a list of 16 health problems common in old age.
Participants indicated whether or not they had experienced these problems over the
past year, resulting in a cumulative index of reported health problems.
A second 4-item measure evaluated reported medical antecedents (i.e. heart
operation; artery or neck operation; hip replacement; diabetes); higher scores were
indicative of a greater number of antecedents.
Given that visual and hearing impairments are relevant to subjective health (Lee
et al. 2005), measures of visual and auditory acuity were included, in the form of
two questions asking the participants to assess their vision (with glasses or contacts
if worn) and hearing (with a hearing aid if worn) using a 5-point response scale (1 =
excellent; 2 = good; 3 = fair; 4 = poor; 5 = incapable of hearing/seeing); higher
scores reflected poorer auditory and visual acuity.

Functional status Functional status was defined as the capacity to perform activities of
daily living (ADL) and functional mobility. Questions assessing the capacity to perform
ADL were from the Older Americans Resources Survey (Multidimensional functional
assessment 1978). Both physical ADL (PADL) and instrumental ADL (IADL) were
assessed, each with a scale comprising seven items. Participants indicated whether
they could perform each activity without help, with help, or if it was impossible for
them to perform the activity. The maximum score for each scale was 14, thus 28 for
the complete scale, with a higher score reflecting a better functional status.
44 Ageing Int (2010) 35:38–60

Significantly elevated correlations (tau = .83, r=.89, p<.001) were found between
this measure and assessments of functional status by qualified professionals,
suggesting very good criterion validity. In addition, a very good inter-rater reliability
has been reported for this measure (.87; α=.001) (Fillenbaum and Smyer 1981;
George and Fillenbaum 1985). Alpha coefficients of .71 and .78 were respectively
found for the PADL and IADL scales among the sample of the present study.
Functional mobility was assessed with the Timed Up & Go Test (TUG; Podsiadlo and
Richardson 1989, 1991). It measures the amount of time needed for the person to lift
from a chair, walk a distance of 3 m, turn, walk back to the chair, and sit. The TUG
allows the identification of older adults susceptible to falls with an 87% degree of
sensitivity and reliability (Shumway-Cook et al. 2000). Elevated correlation
coefficients (r=−.69 and −.70) were found between the TUG and ADL scales among
CSHA participants, suggesting satisfactory construct validity (Rockwood et al. 2000).

Psychological well-being Indicators of psychological well-being included life

satisfaction, general mental health, and positive psychological functioning. Life
statisfaction was assessed with an 11-item adaptation of the Terrible-Delightful Scales
(Andrews and Withey 1976), evaluating on a 7-point scale (0 = terrible; 6 = delighted)
satisfaction toward: health, family relationships, friendships, housing, finances,
residential neighborhood, activities, religion, transportation, life partner, as well as
general life satisfaction. A Cronbach alpha coefficient of .81 was calculated with the
sample of the present study, indicating very good internal consistency. A similar level
of internal consistency has been reported recently (alpha=0.74) (Chappell and Dujela
2008). An exploratory factor analysis with forced one factor solution also indicated
significant factor loadings for all items, with a minimum factor loading of .46.
The index of general mental health was composed of five items from the Medical
Outcomes Study Short-Form Health Survey (SF-36) which assesses anxiety,
depression and positive psychological well-being (Ware 1993). Scores were
transformed so that a higher score corresponded to better mental health. An alpha
coefficient of .80 was calculated for the sample of the current study, and an
exploratory factor analysis supported the presence of one factor, with significant
factor loadings of .55 or more for each item.
Positive psychological functioning was assessed with the abridged version of
Ryff’s Scales of Psychological Well-being (Ryff 1989a, b), which comprises these 6
subscales, each with three items: Self-Acceptance; Positive Relations with Others;
Autonomy; Environmental Mastery; Purpose in Life; and Personal Growth. Low
internal consistency coefficients, ranging from .33 to .56, have been reported for
these abridged subscales (Ryff and Keyes 1995). Also the factorial structure of the
abridged scale has received inconsistent support (Clarke et al. 2001; Guindon et al.
2004; Kafka and Kozma 2002).
An adaptation of Ryff’s scales to improve psychometric properties was deemed
necessary for this study. First, an alpha coefficient of 0.64 was calculated with the 18
items combined. Items reducing the internal consistency coefficient were removed
one by one, resulting in the elimination of the entire Purpose in Life subscale, two
items from the Personal Growth subscale (« I think it is important to have new
experiences that challenge how you think about yourself and the world» and «I gave
up trying to make big improvements or changes in my life a long time ago »), and
Ageing Int (2010) 35:38–60 45

one item from the Autonomy subscale (« I tend to be influenced by people with
strong opinions »). This resulted in a 12-item scale with alpha coefficients of 0.67
and 0.71 for male and female participants. Confirmatory factor analyses were
completed to test the proposed model structure consisting in one latent variable (i.e.
positive psychological functioning) and 12 observed variables (i.e. retained items).
As expected, significant error covariances were found between certain items that
initially belonged to the same subscale or presented with content overlap. Acceptable
fit indices for the model were found, χ2 (48, N=1997)=355.65, p<.001; AGFI=.95;
CFI=.91; RMSEA=.057 and χ2 (48, N=1,332)=216.55, p<.001; AGFI=.96;
CFI=.92; RMSEA=.051, for women and men). A cross-validation analysis indicated
that the model structure was valid, as it did not vary significantly between randomly-
selected samples from the original sample. This revised scale mostly excludes
dimensions of positive psychological functioning that have been found to be weaker
in later adulthood (i.e. Purpose in Life and Personal Growth; Ryff 1989b, 1991, 1995;
Ryff and Keyes 1995). The revised scale therefore appears to reunite more cohesive
indicators of positive psychological functioning at this stage of life (i.e. Self-
Acceptance, Positive Relations with Others, Autonomy, Environmental Mastery).

Social support The social support measure was based on the Medical Outcomes Study
Social Support Survey (Ware 1993) and adapted to an older adult population. It
includes 6 items evaluating satisfaction toward the perceived amount of instrumental,
emotional and informational forms of support, as well as the sense of belonging. The
presence of one factor was supported by an exploratory factor analysis, as well as a
confirmatory factor analysis (CFI=.97, AGFI=.98, RMSEA=.05 for men; CFI=.98,
AGFI=.97 and RMSEA=.06 for women). The internal consistency of this measure
was also deemed acceptable given its limited number of items (alpha=0.69).

Analytic Procedure

Structural Equation Modeling (SEM) analyses were completed with AMOS-5

(Arbuckle 2003) to assess the fit of the proposed model. The subjective health
measure was treated as continuous, as it is not possible to consider the categorical
nature of a variable in analyses performed by this program. The use of categorical
variables can lead to inflated χ2 values as well as attenuated correlation coefficients,
factor loadings, and standard error estimates mostly when variables are abnormally
distributed and/or comprise less than five categories (Byrne 2001), which was not the
case with the subjective health measure. The Bootstrap Maximum Likelihood
procedure was applied to minimize the possible impact of abnormal data distributions
on model estimates. Model fit was evaluated with the Comparative Fit Index (CFI),
the Adjusted Goodness-of-Fit Index (AGFI) and the Root Mean Square Error of
Approximation (RMSEA). The chi-square statistic was not considered due to its
hypersensitivity to sample size (Byrne 2001). An acceptable degree of model fit is
generally reflected by AGFI and CFI indices equal to or greater than .90, and a
RMSEA equal to or less than .08 (Byrne 2001; McDonald and Ho 2002). A
Confirmatory Factor Analysis (CFA) was first completed to confirm that the observed
variables included in the model measured their respective latent variables. Given that
46 Ageing Int (2010) 35:38–60

the fit of the measurement models was judged to be satisfactory, the proposed
relationships (i.e. structure) between the different variables included in the model
were subsequently tested. In order to satisfy identification requirements of the model,
the reciprocal relationships between the Psychological Well-Being variable and
Physical Health and Functional Status variables were evaluated separately. Cross-
validation invariance analyses were subsequently completed to ascertain the statistical
equivalence of the model between sub-samples and thus further test its validity.
Finally, the models (for men and women samples) supported by previous cross-
sectional SEM analyses were tested with subjective health measured six years later
(Time 2), taking into account initial subjective health (Time 1). Invariance analyses
were again undertaken to further test the validity of the final longitudinal models.

Results

Preliminary Analyses

Missing data analyses revealed that 20 men (1.40%) and 42 women (1.93%) responded
to less than 50% of items, and they were excluded from subsequent analyses. This left a
total sample of 2,129 female and 1,408 male participants. Almost all participants
(95.94% of men and 93.87% of women) responded to 95% or more of the items. Only
1.30% and 2.23% of missing data were found for men and women samples, respectively.
The Expectation-Maximization algorithm was used to estimate missing data, as this
method is considered superior to analysis of complete data (listwise and pairwise
deletion) and mean substitution (Graham et al. 2003; Schafer and Graham 2002).
Skewness and kurtosis indices revealed that measures were overall fairly normally
distributed. Notably, the skew and kurtosis indices for the subjective health measure at
Time 1 were, respectively, −.59 and .95 for women and −.70 and 1.76 for men. Similar
values were found for subjective health at Time 2 (−.54 and .74 for women; −.61 and
1.23 for men). However, distribution of the three measures of functional status deviated
significantly from normal. Transformations were therefore applied to improve
distribution of these measures and the Bootstrap procedure was used to estimate all
parameters in subsequent SEM analyses. The latter procedure is considered effective in
reducing the influence of abnormal data distributions in large samples (Byrne 2001).
Scatter plots suggested satisfactory linearity. Multicollinerarity analyses revealed an
absence of correlations above .90 between variables (see Tables 1 and 2), as well as
tolerance indices superior to 10% and variance inflation factor ratios inferior to 10 for
each variable, which indicates that multicollinerarity was not present (Kline 1998).
Multivariate outliers were excluded from further analyses, resulting in a final sample
of 2,022 female and 1,336 male participants. From this sample, 1,426 female and 868
male participants evaluated their subjective health in CSHA-3 and were thus included
in the longitudinal analyses.

Cross-Sectional Test of the Integrative Model

Results of the SEM analyses revealed an acceptable degree of fit for the proposed
model of subjective health for both women and men (respectively: AGFI=.95;
Table 1 Bivariate correlations between observed variables of the model for women (N=2,022)

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Ageing Int (2010) 35:38–60

1. Subjective Health 1.00

2. Age −.06** 1.00
3. Education .12** −.06** 1.00
4. Visual Acuity −.28** .26** −.18** 1.00
5. Auditory Acuity −.19** .22** −.12** .30** 1.00
6. Health problems −.45** .19** −.08** .30** .30** 1.00
7. Medical Antecedents −.16** .06** −.02 .05** .02 .15** 1.00
8. PADL .25** −.31** .03 −.16** −.13** −.32** −.16** 1.00
9. IADL .32** −.40** .02 −.24** −.18** −.36** −.16** .53** 1.00
10. Mobility −.26** .32** −.09** .20** .11** .27** .14** −.51** −.48** 1.00
11. Social Support .19** −.06** −.01 −.08** −.12** −.27** −.06** .12** .19** −.11** 1.00
12. Mental Health .37** .01 .10** −.16** −.13** −.32** −.06** .12** .21** −.10** .32** 1.00
13. Positive Psy. Funct. .27** −.05* .13** −.17** −.17** −.25** −.05** .10** .14** −.08** .28** .41** 1.00
14. Life Sat. .42** −.10** .09** −.22** −.16** −.36** −.09** .20** .25** −.21** .32** .43** .53** 1.00

PADL physical activities of daily living, IADL instrumental activities of daily living
* p<.05. ** p<.01
47
 48

Table 2 Bivariate correlations between observed variables of the model for men (N=1,336)

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14

1. Subjective Health 1.00

2. Age −.04 1.00
3. Education .09** −.07** 1.00
4. Visual Acuity −.19** .14** −.11** 1.00
5. Auditory Acuity −.17** .14** −.13** .18** 1.00
6. Health problems −.45** .11** −.06* .23** .24** 1.00
7. Medical Antecedents −.12** .02 −.06* .05* −.01 .21** 1.00
8. PADL .14** −.19** .06* −.06* −.07** −.16** −.06** 1.00
9. IADL .28** −.19** .04 −.17** −.17** −.29** −.11** .34** 1.00
10. Mobility −.16** .25** −.08** .09** .09** .19** .08** −.31** −.26** 1.00
11. Social Support .10** −.03 −.02 −.11** −.06* −.17** −.04 .11** .12** −.08** 1.00
12. Mental Health .31** −.01 .01 −.14** −.09** −.31** −.07** .13** .14** −.13** .25** 1.00
13. Positive Psy. Funct. .19** −.03 .06* −.15** −.12** −.22** −.05* .02 .09** −.04 .24** .41** 1.00
14. Life Sat. .36** −.06* .06* −.19** −.11** −.30** −.08** .11** .11** −.09** .25** .39** .46** 1.00

PADL physical activities of daily living, IADL instrumental activities of daily living
* p<.05. ** p<.01
Ageing Int (2010) 35:38–60
Ageing Int (2010) 35:38–60 49

CFI=.93; RMSEA=.057 and AGFI=.96; CFI=.92; RMSEA=.047). Estimates for

the reciprocal relationship between Psychological Well-Being and Functional Status
were however inadmissible and removed from the model. Other non-significant paths
were also deleted from the model, with the exception of the path Functional Status →
Subjective Health which was statistically non-significant for men yet retained due to
its theoretical significance. Modification indices suggested a possible relationship
between Age and Subjective Health and this path was added to the model. Post hoc
analyses were completed following the above-mentioned modifications to the model
and results suggested a slight improvement in model fit for women and men
(respectively: AGFI =.95; CFI =.94; RMSEA=.052 and AGFI= .96; CFI= .92;
RMSEA=.045). Cross-validation analyses of the modified models revealed that
their structure did not significantly vary from one sample to the next, which strongly

Fig. 2 a Final model of subjective health for women (Time 1). b Final model of subjective health for men
(Time 1)
50 Ageing Int (2010) 35:38–60

Life
Satisfaction

Fig. 2 (continued)

supported their validity. Final models of subjective health for women and men are
respectively presented in Fig. 2a and b.
In sum, hypothesized relationships in the proposed model of subjective health
were partially supported. To reiterate, the main hypotheses were that psychological
well-being would have a direct effect on subjective health, as well as an indirect one
through physical health and functional status, and that social support would have an
indirect effect on subjective health via psychological well-being.
As predicted, for both women and men respectively, psychological well-being
exerted direct (b=.16, p<.001; b=.13, p<.01) and indirect (b=.35, p<.001; b=.31,
p<.001) effects on subjective health, resulting in considerable total effects (b=.51,
p<.001; b=.44, p<.001). While psychological well-being was associated with less
physical health problems (b=−.62, p<.001 for women; b=−.57, p<.001 for men), no
relationship was found with functional status, suggesting that the indirect effects
occurred through physical health exclusively. As hypothesized, social support also
Ageing Int (2010) 35:38–60 51

had indirect effects on subjective health (b=.23, p<.001 for women; b=.16, p<.001
for men) through its direct positive effect on the psychological well-being of both
women and men (b=.45, p<.001; b=.37, p<.001 respectively). Furthermore, age
was associated with a greater number of physical health problems (b=.32, p<.001
for women; b=.17, p<.001 for men) and a poorer functional status (b=−.30, p<.001
for women; b=−.27, p<.001 for men). Higher education was associated with fewer
physical health problems for both sexes (b=−.08, p<.01; b=−.11, p<.001 for
women and men respectively), whereas it predicted better psychological well-being
in women only (b=.16, p<.001). Not surprisingly, physical health problems were
associated with poorer subjective health (b=−.52, p <.001 for women; b=−.50,
p< .001 for men) and poorer functional status (b=−.54, p<.001 for women; b=−.50,
p<.001 for men). Better functional status was associated with better subjective health
for both sexes (b=.09), yet achieved a minimal degree of statistical significance
(p<.05) in women only. The total explained variance of subjective health reached
43% for women and 38% for men.
Contrary to expectations, older age was directly associated with better subjective
health (b=.18, p<.001; b=.10, p<.001 for women and men respectively), whereas
education was not significantly associated with subjective health for neither sexes, nor
with psychological well-being and functional status for men. A very weak negative
association was found between women’s education and functional status (b=−.07,
p<.01). Indirect positive effects were found between women’s education and
subjective health (b=.12, p<.001). Results suggested a unidirectional (as opposed to
reciprocal) relationship between psychological well-being and physical health for both
sexes. Specifically, the effect of psychological well-being on physical health was
significant, but not the reverse. Finally, as previously mentioned, results suggested an
absence of relationship between psychological well-being and functional status.

Longitudinal Test of the Proposed Model

Results of the longitudinal analyses suggested an appropriate model fit for both
women and men (respectively AGFI=.95; CFI=.94; RMSEA=.048 and AGFI=.95;
CFI=.91; RMSEA=.045). Certain non significant path coefficients lead to the deletion
of corresponding links, and post hoc analyses again suggested an acceptable model fit
(AGFI=.95; CFI=.94; RMSEA=.048 and AGFI=.95; CFI=.91; RMSEA=.044 for
women and men respectively). Validity of these models was also supported by cross-
validation analyses, which suggested that their structure did not vary significantly
from one sub-sample to another. Final models of subjective health at Time 2 for
women and men are presented in Fig. 3a and b respectively.
As predicted, subjective health measured at Time 1 was significantly associated
with subjective health at Time 2 (b=.29, p<.001 for women; b=.23, p<.01 for men).
For men, psychological well-being had both significant direct (b=.15, p<.01) and
indirect effects on subjective health at Time 2, with total effects rising significantly
(b=.34, p<.001). While the direct effect of psychological well-being on subjective
health at Time 2 was not significant for women, significant indirect effects were
found (b=.33, p<.001). Social support also continued to have a small indirect
positive effect on subjective health at Time 2 (b=.15, p<.01 for women; b=.14, p<.01
for men). A greater number of physical health problems had both direct (b=−.30,
52 Ageing Int (2010) 35:38–60

a .60 .60 .45

Positive Life
Mental Psych.
Health Satisfaction
Funct.

.63 .64 .74

Social .45
Psychological .78
Support
Well-Being
.58 .72
.16 .16

Age
.14 Subjective .29 Subjective
.26 Health Health
-.27 -.62 T1 T2

-.51 -.30
.06
Education -.08
-.08
Physical Functional .59
.52 Health -.52 Status
Problems
.40 .19 -.64
.38 .67 .76
.71

Visual Auditory Antece PADL IADL Mobility

Illness
Acuity Acuity dents

.84 .86 .50 .96 .55 .42 .59

.18

Fig. 3 a Final model of subjective health for women (Time 2). b Final model of subjective health for men
(Time 2)

p<.001 for women; b=−.19, p<.01 for men) and indirect negative effects on
subjective health at Time 2, resulting in significantly elevated total effects (b=−.46,
p<.001 for women; b=−.30, p<.001 for men). The effect of functional status on
both women and men’s subjective health at Time 2 was not significant. Contrary to
expectation, age for both genders and psychological well-being for women did not
have significant direct effects on subjective health across time. The total explained
variance of subjective health at Time 2 was 28% for women and 21% for men.

Discussion

The primary aim of the present study was to examine the contributions of
psychological well-being and social support to an integrative model of subjective
health in older adults, concurrently and over time. Overall, both cross-sectional and
longitudinal SEM results support the proposed integrative model of subjective
health, as suggested by adequate model fit indices and significant variable
Ageing Int (2010) 35:38–60 53

b .68 .60 .53

.84
.67 .79

.55
.70

.84 .88 .49 .95 .81 .70 .85

Fig. 3 (continued)

interrelationships. It is remarkable that the contributions of the different variables in

the model were overall very similar in men and women. This contrasts with results
of other studies that found gender differences in the predictors of subjective health
(e.g. Gonzalez et al. 2002; Prus and Gee 2003).
Results provide strong support for the main hypothesis that psychological well-
being affects subjective health directly and indirectly (although only indirect effects
were observed for women at Time 2). The direct effect of psychological well-being
on subjective health may reflect the influence of psychological well-being on
memory and other cognitive processes that may be involved in the evaluation of
health, such as downward social comparisons (Henchoz et al. 2008; Jylhä 1994;
Kaplan and Baron-Epel 2003; Krause and Jay 1994; Suls et al. 1991), which refer to
the tendency to maintain a positive perception of one’s health by comparing oneself
to others in poorer health. As Wurm and her colleagues recently pointed out (Wurm
et al. 2008), a positive view of ageing affects subjective health and life satisfaction
even in the face of serious health problems, and thus represents a psychological
resource that fosters resilience.
54 Ageing Int (2010) 35:38–60

The finding of an indirect effect of psychological well-being on subjective health

via physical health finds an echo in emerging evidence showing how physical health
can be positively affected by various dimensions of psychological well-being
including positive affect (Fredrickson and Levenson 1998; Ostir et al. 2001a; Ostir et
al. 2004; Ostir et al. 2001b; Xu 2006), optimism (Kubzansky et al. 2001; Reed et al.
1999; Segerstrom et al. 1998), and perception of control (Chipperfield et al. 2004).
As predicted, greater satisfaction with available social support had direct and indirect
positive effects on psychological well-being and subjective health, respectively. These
effects were found in both cross-sectional and longitudinal analyses. It should be noted
however that the indirect effects of social support on subjective health, although
significant, were small. Some studies that distinguished between emotional and
instrumental support have reported that availability of emotional support was associated
with better subjective health, whereas greater instrumental support was associated with
poorer subjective health (Liu et al. 1995; Zunzunegui et al. 2001). It is therefore
possible that larger effects could be found for emotional support specifically. This
hypothesis could not be tested in the present study since these two types of support
were not distinguished in the measure of social support used. A more detailed
understanding of the effects of social support on subjective health might be achieved
with the use of distinct measures of these different forms of social support.
Not surprisingly, physical health problems were significantly associated with
subjective health and continued to have a significant effect at Time 2, both directly
and indirectly through subjective health measured at Time 1. A surprising result was
the lack of effect of physical health problems on psychological well-being for both
sexes. Several studies have shown that psychological (or subjective) well-being
tends to remain relatively stable and minimally affected by life events in the long
term (DeNeve and Cooper 1998; Eid and Diener 2003; Stones et al. 1995; Suh et al.
1996). This stability may be rooted in personality (Duberstein et al. 2003; Suh et al.
1996) or genetic predispositions (Nes et al. 2006). The limited effect of life events
on psychological well-being may also reflect the capacity of human beings to adapt
to major challenges such as health problems.
As expected, age had an unfavorable effect on physical health problems and
functional status. Consistent with results of other studies (Hays et al. 1996; Idler
1993; Johnson and Wolinsky 1993; Landau and Litwin 2001; Lee and Shinkai 2003;
Mulsant et al. 1997), a small yet significant relationship was found between older
age and better subjective health at Time 1. This finding should however be
interpreted with caution, as results were inconsistent in the longitudinal test.
Other hypothesized links between certain variables of the model were not
significant. For instance, education appeared to be associated with greater
psychological well-being and better subjective health, but only for women. Results
also suggested that functional status had a minimal effect on subjective health for
both sexes, which is congruent with results of other studies (Nybo et al. 2001; Stump
et al. 1997). It may be that older adults expect a certain degree of physical limitations
at this stage of life and thus evaluate their health based on this expectation rather
than that of an “ideal” or “perfect” health (Nybo et al. 2001).
Although a substantial amount of subjective health’s variance was explained by
the final model, a certain amount of variance was left unexplained. Other variables
excluded from the proposed model may also contribute to explain subjective health
Ageing Int (2010) 35:38–60 55

in later life, such as potential risk factors like pain, psychological distress, and life
stressors. On the other hand, other protective factors could also be considered, such
as positive coping strategies, healthy lifestyle, positive affect, personality traits (e.g.
optimism; sociability), and favorable cognitive processes such as downward social
comparisons and positive illusions.
Some limitations of the present study need to be acknowledged. A major dis-
advantage of secondary data analyses consists in the imposed selection of measures.
Findings of this study are limited by the conceptual and methodological restrictions of
some of its measures. For instance, the evaluation of psychological well-being included
a measure of general mental health which contained questions related to depression and
anxiety that are indeed more indicative of psychological distress than well-being.
Furthermore, Ryff’s Scales of Psychological Well-being and the social support scales
were adaptations of the original scales. Measures of physical health and functional
status can also be criticized for being based on self-report, and thus susceptible to
under- or over-reporting biases. While measurement of subjective health with a single
item can also be considered an issue, there is extensive evidence to support its use (see
above description of this measure). Although the investigation was rendered more
rigorous with the adoption of SEM as an advanced method of analysis, the analyses
remain correlational in nature, and thus cannot truly establish causal relationships
between variables (Kline 1998). Nonetheless, findings from the longitudinal analyses
provide some tentative support for such type of relationship between the variables in
the proposed model and subjective health. Finally, it should be recalled that
participants of the present study resided in the community, and did not present with
significant cognitive impairments. Therefore, results may not be generalizable to
older adults with differing characteristics, such as individuals with lower autonomy.
In conclusion, results of this study emphasize the determining role of psycho-
logical well-being, in terms of good mental health, satisfaction with life and positive
psychological functioning, for older adults’ perceptions of their health. The final
model illustrates how psychological well-being conceived in this manner can
influence subjective health, both directly and indirectly through its favorable effect
on physical health. Considering the predictive power of subjective health on other
important outcomes such as functional decline and mortality, implications of these
results are important. At a theoretical level, they confirm the validity of integrative or
holistic models of subjective health, such as those proposed by Mossey (1995) and
in the present study. Furthermore, while existing research has mainly focused on the
negative effects of psychological distress on subjective health, this study supports
the relevance of studying protective psychological resources that may promote better
subjective health in later adulthood. This line of investigation could also help
elucidate the reason many older adults rate their health positively even when faced
with physical health problems.
At a clinical level, the results point to the need to promote greater psychological well-
being in order to improve subjective health. Various types of interventions could be
considered. In particular, findings of this study suggest that social support may have a
significant effect on psychological well-being, and a resulting indirect effect on
subjective health. Clinicians working with older adults should thus be aware of the
possible needs for social support among their clients and provide referrals to appropriate
community resources for those with limited support. Furthermore, strategies aiming to
56 Ageing Int (2010) 35:38–60

achieve greater psychological well-being without requiring professional assistance have

been described in the literature (e.g. Fredrickson and Levenson 1998; Seligman et al.
2005), and could potentially also have positive effects on subjective health in the later
stages of life. Clinical implications of this study incite the development of social
policies that would facilitate older adults’ access to life conditions and resources that
are likely to promote more optimal levels of psychological well-being and, in turn,
better subjective health and associated outcomes.

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60 Ageing Int (2010) 35:38–60

Sophie Guindon is a clinical psychologist working with adults, in particular older adults, in hospital-
based practice. She graduated from the University of Ottawa with a Ph.D. in clinical psychology in 2007.
Previously she had completed a Master’s degree in Psychology at the Université de Montréal. Her clinical
and research interests relate to psychological interventions with individuals and couples for depression and
anxiety.

Philippe Cappeliez is Full Professor at the School of Psychology, University of Ottawa, which he initially
joined in 1984. He is also affiliated with the Elisabeth Bruyère Research Institute (Ottawa). He obtained
his Ph.D. in clinical psychology at McGill University (1981), after undergraduate and graduate studies
(Licence en psychologie) at Université Catholique de Louvain (Belgium). He is Fellow of the Canadian
Psychological Association. He teaches cognitive-behavior therapy and clinical psychology of aging to
graduate students in clinical psychology, and psychology of aging and research topics in gerontology to
undergraduate students in psychology and gerontology. Depression in older adulthood, in particular
psychological treatments such as reminiscence therapy, and the functions of reminiscence constitute his
main research interests.