Assessment of a short scale to measure
social support among older people
Abstract
Background: Social support strongly
influences health, but research has been
limited by the paucity of brief, inexpensive,
psychometrically sound scales suitable for
use with older people.
Method: The validity and reliability of the
11-item Duke Social Support Index (DSSI)
were tested among a random sample of
565 community dwelling people aged 70
years and over.
Results: A response rate of 76% was
obtained. Participants had a mean age of
76 years. Internal consistency using
Cronbachs alpha for the overall index was
0.77. Test-retest reliability (n=117) scores
ranged from 0.70 to 0.81. Concurrent
validity is supported by the DSSl’s
moderate to strong correlations with the
Interview Schedule for Social Interaction.
Construct validity of the DSSI was
supported by moderate correla!ions with
health, quality of life and loneliness. To
further test construct validity a multiple
regression model was used and 25.6% of
the variance in social support was
explained using three expected variables;
self rated health, quality of life, and living
arrangements.
Conclusion: Strong evidence for reliability
and validity of the 11-item Duke Social
Support Index support its use in aged care
research and health promotion strategies.
Implications: The DSSI provides
researchers with the opportunity to use a
brief measure of social support which has
been assessed specifically with older
Australians instead of single-item
measures or scales which have limited
psychometric evidence.
(AuSf N Z J Public Health 1999; 23:260-5)
Submitted: October 1998
Revision requested: February 1999
Accepted: April 1999
260 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH
Brendan Goodger, Julie Byles and Nick Higganbotham
Centre for Clinical Epidemiology and Biostatistics, University of Newcastle,
New South Wales
Gita Mishra
Department of Statistics, University of Newcastle, New South Wales
T he importance of social support to the status) are convenient but have been criti-
health of older people has been estab- cised for lacking validity.28-10Longer multi-
lished although an understanding of how this dimensional measures of social support may
association occurs is still e v o l ~ i n g .A~ - ~ offer greater sensitivity than shorter meas-
number of longitudinal and cross sectional ures. The difficulty is that longer measures
studies have concluded that people with low may not be well received by older people.
social support have an increased risk of Aged care researchers may have difficulty
premature death and institutionalisation, justifying the inclusion of long measures of
physical and psychological morbidity and an social support where interview schedules are
increased use of community and hospital crowded or in investigations where social
service^.^.'^ support is not the major outcome of interest.
Recent studies of cardio and cerebro vas- In brief, a major impediment to including
cular disease suggest both a causal and con- valid measures of social support in epide-
tributory link between low social support and miological studies involving o l d x people has
premature mortality. Demonstration of been the paucity of brief, inexpensive, psy-
the relationship between social support and chometrically sound scales that can be inter-
health has prompted the development of spe- viewer or self administered.]’
cific social support intervention strategies for Using exploratory factor analysis, Koenig
older people.2i-21However, exploration of the et al. derived the 11-item DSSI from the
links between social support and older peo- much longer 35-item DSSI which has been
ple has been hampered by a lack of consen- used in North American surveys.I2 As part
sus on operational definitions of social sup- of the analysis of the 35-item version, pre-
port, and the use of a plethora of scales which liminary internal reliability and construct
have poor supporting psychometric proper- validation were estimated for the 1 1-item
ties.iJ4-29Uchino et al. note the “rarity in version. However, no further psychometric
which psychometric data regarding the meas- evaluations of the shortened version have
urement of social support were reported”.’ been published to date. The DSSI includes
Only a small number of social support both a subjective evaluation of the adequacy
scales, such as the Interview Schedule for of support received as well as a more objec-
Social Interaction (ISSI) and the Duke Social tive evaluation of type and number of social
Support Index (DSSI), have been validated interactions.The DSSI can be interviewer or
specifically for use with older people. The self administered. This index is currently
ISSI, with 108 items, can only be interviewer being used in two major Australian studies:
administered and takes up to 60 minutes to 1. The Preventive Care Trial is a four-year
complete. In comparison, single-item meas- randomised controlled trial involving
ures of social support (such as marital 1,500 war veterans.*’
Correspondence to:
Brendan Goodger, CCEB, Royal Newcastle Hospital, Newcastle, NSW 2300.
Fax: (02) 4923 6148; e-mail: mdbgg@cc.newcastle.edu.au
1999 VOL. 23 NO. 3

2. The Australian Longitudinal Study on Women’s Health which
has enrolled more than 12,000 elderly women who will be fol-
lowed up for 20 years.’]
To tcst the applicability, reliability and validity of the 11-item
DSSI among older Australians, the present study was conducted
using a representative sample of older people living in an urban
community, Newcastle, New South Wales.
Subjects and methods
A random sample of 565 older people aged 70 years and over
were selected for inclusion in this study. Anticipating that 300 of
these people would be eligible and willing to participate, this sam-
ple size was calculated to allow a correlation coefficient of at
least 0.60 to be detected within a 95% confidence interval of plus
or minus 7 % between the DSSI and the ISSI. The sample was
randomly selected from the Federal electoral roll of Newcastle in
New South Wales which is maintained by the Australian Elec-
toral Commission (with over-sampling of males 55/45). Males
were over sampled to allow equal groups for statistical efficiency
and because of concern over their willingness to participate. As
voting is compulsory in Australia these rolls are continuously
updated; 98% of all eligible older voters are r e g i s ~ e r e d . ~ ~
Selected individuals were sent a personalised letter with an
information pamphlet describing the study. These individuals were
then telephoned one week later to seek their consent and to ar-
range an interview. Participants were considered ineligible for the
study if they were in an institution (nursing home, hostel or hospi-
tal), required an interpreter, could not be contacted according to a
standardised protocol, had poor health such that an interview could
not be completed or were cognitively impaired (a score of less
than 6 on the Mental Status Questionnaire) at the time of inter-
view.35
A nurse and social worker experienced in aged care conducted
the interviews. Two training sessions were held to standardise the
interviews which involved reading standard questions from a
printed interview schedule. Participants were abIe to view the
questions and response options on a flip chart, to enable compre-
hension and allow for hearing difficulty. All interviews were con-
ducted in the participant’s own home. Interviewers and the order
of the DSSI and the ISSI were randomly assigned prior to each
administration to even out the effects of gender and the possible
effects of tiredness affecting participants’ responses. These inter-
views took approximately one hour to complete.
Measures
The main outcomes of interest were the total score and the two
subscale scores on the 1 I-item DSSI.Although factor analysis of
the DSSI by Koenig et al. revealed one factor, two subscale scores
can be ~ a l c u l a t e dThe
. ~ ~social interaction subscale has four items
and the satisfaction subscale has seven items. The total score for
the DSSI ranges from 11-33 with increased values indicating higher
levels of support.
Prior to commencement of data collection, older people’s in-
terpretation and comprehension of the DSSI were assessed in a
1999 VOL. 23 NO. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH
Social support among older people
pilot study with 27 participants. Participants’ comments on each
question were then analysed by an expert panel comprised of three
people, an aged care social worker (BG), an epidemiologist (JB)
and health psychologist (NH).The wording of two questions werc
slightly modified to avoid ambiguity from cultural differences in
interpretation or to improve comprehension.
For example, the word ‘club’ was ambiguous in the Australian
context and could have referred to a ‘place where people of simi-
lar interests go or a club where you can get a meal and a drink and
the pokies’. In America, the word club reflects the former defini-
tion. Question four was amended to refer to meetings of sociul
clubs, religious meetings. or other groups that you belong lo. To
improve comprehension Question 2 which consisted of one sen-
tence was made into two short sentences with the original word-
ing remaining unchanged.
Within the social support literature there is no measure that
has been accepted by researchers as a gold standard. The ISSI
was chosen to assess the concurrent validity of the Duke Index
because its reliability and validity has been well documented and
The ISSI was developed and has been used in
Australia with community dwelling older people. The lSS1 has
five major subscales measuring different dimensions of social
support. Not all of these dimensions are measured in the I 1-item
DSSI. Subscales on the DSSI and ISSI which measure different
constructs were not expected to highly inter-correlate. In addi-
tion, standard single item measures of self-rated health, Ioneli-
ness and quality of life (each with five response categories) were
used to test construct validity. These measures were chosen as
they are commonly csed, are economical and, more importantly,
there is growing evidence of their predictive validity with respect
to health outcome^.^'.^* Standard socio-demographic measures of
marital status, household living arrangements, ethnicity, age, and
gender were included in the interview schedule.
Data analysis
Internal consistency of the DSSI was estimated using
Cronbach’s a l ~ h a . The
4 ~ intraclass correlation and Pearson Prod-
uct moment correlations were used to evaluate the test-retest reli-
ability of the DSSI and its sub scale^.^^ Because of the nature of
the variables Pearson and Spearman correlations were used to as-
sess construct validity and concurrent validity re~pectively.~~
Factor
analysis was performed using principal components analysis with
a varimax rotation.
Initial exploratory analyses involved performing one-way analy-
sis of variance to investigate associations between social support
and self-rated health, quality of life, living arrangement, loneli-
ness, marital status and gender. A multiple regression model was
used to identify correlates of social support and all variables for
which thep values were 0.05 or less were entered into this regres-
sion model. The overall social support score was analysed as a
continuous scale variable; means and standard deviations werc
used to summarise group behaviour.
Adjusted means and 95% confidence intervals of the overall
social support index were calculated for each of the independent
variables in the final model, using the lsmeans option of the
261
Goodger et al.

Table 1: Reliability and validity of the 11 item Duke Social Support Index.
~~ ~

Total Scale Satisfaction Social Interaction

Concurrent Validity
lSSl Subscales
Availabilitv of attachment 0.29" 0.34" 0 09
Availability of social integration 0.57" 0.38' 0.53a
Adequacy of attachment ("7.) 0.37" 0.30a 0.28"
Adequacy of social integration 0.23" 0.28' 0.06
Satisfaction with no nominated attachment (%) 0.30" 0.32" 0.13c
Construct Validity
Loneliness 0.23a 0.28' 0.06
Quality of life -0.40" -0.40a -0.21a
Health -- - 0.35a - 0.36a - 0.18 b
Reliability
Internal consistency 0.77 0.80 0.58
Test Retest 0.70d0.81e 0.6gd O.8Oe 0.5Ed0.74=
Notes:
(a) p value <O.001
(b) p value <0,01
(c) p value <0.05
(d) lntraclass Correlation
(e) Pearson Product Moment Correlation

generalised linear models procedure in SAS.45Bonferroni correc-
tions were used to reduce the effects of inflated type I errors due
to multiple comparisons of the adjusted means.
Results
Sample
After exclusion of ineligible participants, a total of 301 inter-
views were conducted (response rate 76%).The median and mean
ages of these participants were both 76 years; 54.8% were male
and 60% were married. Reasons for exclusion were: non-English
speaking (1 7); not contactable after three attempts (49); deceased
(1 1); on holidays or had moved (38); lived in institutional care
(21); and, a score of 6 or less out of 10 on the mental status ques-
tionnaire or had very poor health (27).The DSSI took around five
minutes to complete for each participant. Scores on the DSSI
ranged from 12-33 and were negatively skewed. This skew
direction suggests that most people had scores indicating high
levels of social support. Test-retest interviews were conducted with
1 17 participants' on average 13 days after the initial interview.
Reliabjljty
Table 1 shows that Cronbach's alpha coefficients and test-retest
reliability were satisfactory for the overall scale and for the seven
item satisfaction subscale. The Social Interaction subscale had
slightly lower reliability scores.
Validity
Table 1 also shows a consistent pattern of low to moderate
correlations between the DSSI and most of the ISSI subscales.
The Availability of Social Integration showed strong correlations
(0.57,0.38, 0.53) with both the overall score of the DSSI and its

Table 2: Factor Loadings of the 11 Duke Social Support Index, items with a two factor varimax rotated factor solution
(n=298).
Social Interaction Satisfaction
1 . Persons you can depend on 0.66 0.09
2. Times spent with others 0.77 0.08
3. Talk to someone on the phone 0.56 0.11
4. How often did you go to social clubs 0.58 0.10
5. Family and friends understand you 0.05 0.79
6. Do you feel useful to family and friends 0.20 0.46
7. Do you know what is going on with family and friends 0.16 0.70
8. Do you feel listened to 0.20 0.63
9. Do you feel you have a definite role 0.27 0.62
10. Can you talk about your deepest problems 0.00 0.73
1 1 . How satisfied are you with relationships 0.02 0.70
Explained X of variation 32% 13%

262 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO.3
 Social support among older people

two subscales. ISSI subscales measuring distinct aspects of social
support such as theAdequacy of Social Integration and Availabil-
ity of attachment had weaker correlations with the DSSl scales.
As expected, moderate associations were found between the
DSSI and single item measures of health, quality o f life and lone-
liness (Table I ) . Poorer levels of self-reported health and quality
of life (higher scores) were associated with lower social support
scores. Also, as loneliness decreased (higher scores), social sup-
port scores increased.
Using principal components analysis with a varimax rotated
solution, two factors were identified which explain a total of 46%
of the variance in the DSSl scores (Table 2). These two factors
Social Interaction and Satisfaction, correspond to the two subscales
within the DSSI. Items within the DSSI loaded as expected on the
appropriate subscale with no significant cross-loadings.
Univariate analyses found that, self rated health @=O.OOOl)
quality of life (p=O.OOO I ) and living arrangements @=0.0284) were
all significantly related to social support. There were no signifi-
cant associations (p >0.05)between social support and loneliness,
gender and marital status on these analyses. Table 3 shows crude
and adjusted mean DSSI scores and standard deviations for the
three variables that significantly contributed to the final regres-
sion model. Significant independent associations @<0.05) were
observed between the DSSI score and fair or poor quality of life,
and living with offspring.
Discussion
In comparison to other scales, the I I-item DSSl has the
advantages of brevity, ease of administration and was well re-
ceived and accepted by older people in this study. These strengths
are supported by moderate to strong reliability and valid-
ity,I .18.?4,?8.29 Internal consistency and test-retest reliability of the
overall index and the satisfaction subscale met or exceeded tho
recommended level o f 0.70?‘ The modest alpha score (0.58)
obtained for the four item social interaction subscale probabiy
reflects more the influence of its length rather than any strong
underlying tendency towards unreliability. Moderate levels of in-
ternal consistency are considered acceptable where the aim is to
preserve content validity for the purposes o f inferential testing.“
Although test-retest reliability is often assessed using Pearson’s
correlation, the intraclass correlation is now being recommendcd
as it is a measure of the average similarity of participants two
In contrast, the Pearson correlation measures asso-
ciation not agreement. Generally, as found in our study, Pearson
correlations produce higher estimates of reliability. Streiner and
Norman describe the Pearson correlation method as being an “in-
appropriate and liberal measure of reliability”.J4The slightly lower
correlations obtained for the social interaction subscale were not
unexpected; these items are more likely to be subject to real
changes during the two week retest interval.
Construct validity of the DSSI is supported by theoretically
consistent correlations obtained between the DSSI and measures
of health, quality of life and loneliness and significant independ-
ent associations between social support and quality of life in the
stepwise regression model. Loneliness was not significantly as-
sociated with social interaction but was related to satisfaction and
the total score. This finding confirms previous research demon-
strating that number of interactions does not equate to how they
are subjectively perceived and a p p r a i ~ e d . ~ ” . ~ ’older
A n person may
feel lonely even when they have a large social network because

Table 3: Meansa standard deviations and confidence intervals of 11-item Duke Social Support Index social support
scores for factors associated with social support.
~

Number Mean Standard Adjusted 95% CI pValueb

Deviation Mean
~~ ~ ~~~ ~ ~~

Self-rated health
Excellent 32 28.7 36 26.2 24.8-27.7 -
-
Very good
-____ 73 28.9 29 26.7 25.6-27.8 1.000
Good
-_____ 87 28.0 2.9 26.0 25.0-27.0 1.000
__ ~-
Poor 73 26.1 3.5 24.9 23.9-25.8 0.325
__-- ~- -
Very poor 30 25.0 4.6 24.8 23.5-26.1 0 498
Quality of life
Very good 121 28.8 2.7 27.8 27 0-28.6 -
Good 104 27.6 3.2 27.1 26.3-27.9 0.464
Fair 49 25.7 3.3 25.7 24.6-26.8 0.038
PoorNery poor 21 24.0 5.7 24.2 22.7-25.7 0.006
Living arrangement
Alone 102 27.7 3.8 26.7 25.9-27.5 -
Spouselpartner 159 27.6 3.4 26.2 25.5-26.9 0.709
~-
Daughterkon
. 16 24.9 3.1 23.9 22.2-25.5 0.004
Other 18 27.8 3.5 26.1 24.5-27.7 1.000
.. ~

Notes:
(a) Means were adjusted for all the other variables in the model.
(b) p-values for painvise comparisons with the first category of each variable, after Bonferroni correction for multiple comparisons (i.e. multiplying the paimise p-value
bya factor offour for variable self-rated health andbya factorof three for-variablesquality of life andliving arrangement).
.-.

1999 VOL. 23 NO.3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 263
Goodger et al.
they may not know members well enough to feel supported or this
network may not provide emotional support. Marital status and
gender was not significantly associated with the DSSI at any level
of analysis. Furthermore, the adjusted mean scores between those
living alone and those who are married were similar.
Previous research suggests two possible reasons for this lack
ofassociation. First, the majority ofthose living alone were women
and it is well known that women have both a larger number of
social contacts, enjoy greater emotional interaction and a higher
number of confidantes within their social network than men liv-
ing by themselves. A second reason is that the DSSI does not
include questions that focus specifically on marriage. Koenig et
al. and others have argued that relationships such as family, friends
and neighbours may make equally important contributions to the
level of social support received by older people, of which a sig-
nificant number live aIone.ZJ4~3z These friendships may provide
an alternative source of equally valued emotional and tangible
support for older people living by themselves. The lack of asso-
ciation between gender and social support probably reflects the
effect of over representation of males.The majority of males (72%)
in this study were married. The greatest source of informal care
for men is their spouse while for older women regardless of mari-
tal status friends and other family assume more importance.
The finding of a significant negative association between social
support and living with one’s children suggests that there is a level
where too much contact may not promote a feeling of support and
may isolate older people from other relationships. This is espe-
cially so if the older person living with his or her children de-
pends on them for physical care. The stress of caring has been
well d o ~ u m e n t e d . ~ ~ . ~ ~
Concurrent validity is demonstrated by the pattern of strong to
moderate correlations between the DSSI and the ISSI subscales
with the greatest similarity in content. As expected, the Social
Interaction subscale, which attempts to measure social
embeddedness, was not significantly associated with the ISSI
subscales assessing the perceived Availability ofAttachment and
Adequacy of Social 1ntegration.These results emphasise the suit-
ability of the 11 item DSSI as a substitute for the ISSI as it cap-
tures the shared dimensions in a parsimonious manner.
In contrast to Koenig et al.’s preliminary validation of the 1 1-
item DSSI we identified two factors called Social Interaction and
Satisfa~tion.~*This factor structure suggests that the DSSI is able
to clearly differentiate between social interaction and satisfaction
as dimensions of social support.
A limitation of our study is that those who were in poor health
or living in institutional care were systematically excluded. This
occurred because of ethical concerns about interviewing people
who were obviously unwell. Our results apply only to community-
dwelling older people. In this study, 8.5% people were excluded
for the reasons stated above and a further proportion would not be
included in the sampling frame due to removal of some older
people who are chronically unwell from the electoral rolls. If
anything their exclusion has the conservative effect of under-
estimating the strength of association between health, quality of
life, loneliness and social support as summarised in Table 1.
264 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH
Consequently, these results could have been influenced by the
composition of the sample who were relatively healthy.
A further difficulty in this study, typical of social support re-
search, is the lack o f a gold standard with which to compare social
support measures. Two measures of social support are unlikely to
define or measure social support in the same way. This can make
interpretation of results more difficult when assessing concurrent
validity. The approach we have taken is to use the ISSI as a crite-
rion measure because its psychometric properties have been com-
prehensively assessed and tested for use in Australia with older
pe~ple.~~-~~
The compact nature of the I I-item DSSI is a major strength,
but the number of dimensions it can measure are clearly limited.
Researchers when choosing an instrument must identify those
hypothesised dimensions most relevant to their research area while
taking into account its psychometric properties and practical is-
sues of scale administration. The 1 I-item DSSI appears to be a
promising measure of social support particularly suited to epide-
miological research in aged care.
Acknowledgments
This research was supported by a grant from the Australian
Government under the then Commonwealth Department of Fam-
ily and Community Services.
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1999 VOL. 23 NO. 3
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