Social Indicators Research (2006) 77: 521548 DOI 10.

1007/s11205-005-7746-y

Springer 2006

GRAEME HAWTHORNE

MEASURING SOCIAL ISOLATION IN OLDER ADULTS: DEVELOPMENT AND INITIAL VALIDATION OF THE FRIENDSHIP SCALE
(Accepted 23 May 2005)

ABSTRACT. Although there are many excellent published scales measuring social isolation, there is need for a short, user-friendly, stand alone scale measuring felt social isolation with good psychometric properties. This study reports the development and preliminary validation of a short, user-friendly scale, the Friendship Scale. The six items measure six of the seven important dimensions that contribute to social isolation and its opposite, social connection. The psychometric properties suggest that it has excellent internal structures as assessed by structural equation modelling (CFI = 0.99, RMSEA = 0.02), that it possesses reliability (Cronbach a = 0.83) and discrimination when assessed against two other short social relationship scales. Tests of concurrent discriminant validity suggest it is sensitive to the known correlates of social isolation. Although further work is needed to validate it in other populations, the results of this study suggest researchers may nd the Friendship Scale particularly useful in epidemiology, population surveys or in health-related quality of life evaluation studies where a parsimonious measure of felt social support or social isolation is needed. KEY WORDS: loneliness, social connectedness, social isolation, social

relationships, social support

INTRODUCTION Social isolation refers to living without companionship, social support or social connectedness. It is the absence of signicant others someone interrelates with, trusts, and turns to in time of crisis. It is associated with poorer health-related quality of life (HRQoL), life meaning, levels of satisfaction, wellbeing and community involvement (Cantor and Sanderson 1999). The socially isolated suer worse health status, have a higher consumption of health care resources (Ellaway et al., 1999) and have poorer outcomes from acute interventions, such as cardiovascular surgery (Ruberman et al., 1984;

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Williams et al., 1992; Farmer et al., 1996). In addition there are associations between social isolation and mental illness, distress, dementia, suicide and premature death (Berkman and Syme, 1979; Turner, 1981; House et al., 1982; Lester and Yang, 1992; Kawachi et al., 1996; Fratiglioni et al., 2000; Rokach, 2000; Ellis and Hickie, 2001). The key correlate of social isolation is personal relationships (Polansky, 1985; Maxwell and Coebergh, 1986; Dykstra, 1990, 1995; Mullins et al., 1996; Plopa, 1996; Gierveld, 1998). Other correlates include network characteristics such as neighbourhood friendliness and social initiation, geographic location, living alone or homelessness, and ethnicity (Polansky, 1985; Cutrona, 1986; Lewin Epstein, 1991; Straits Troester et al., 1994; Mullins et al., 1996; Scheier and Botvin, 1996; Gallagher et al., 1997; Gierveld, 1998). Both physical and mental health status are also predictive of social isolation (Cobb, 1976; Thoits, 1982; Mullins et al., 1996; Ploue and Jomphe Hill, 1996), as are aging communication losses (Retsinas and Garrity, 1985; Maxwell and Coebergh, 1986). Other correlates include economic resources such as employment status and income (Polansky, 1985; Maxwell and Coebergh, 1986; Lewin Epstein, 1991; Mullins et al., 1996; De Jong-Gierveld and van Tilburg, 1999). It is widely accepted that the prevalence of social isolation is between 325%. It is a stereotype of later life that there is a network of loneliness, social isolation and neglect (Victor et al., 2000; Baltes and Smith, 2002) related to diculties with mild cognitive impairment, performing activities of daily living, declining health status, partner loss, and institutionalization (van Oostrom et al., 1995). The measurement of social isolation is important in studies of older adults because it may inuence their participation in and response to public health interventions as well as being an outcome in its own right. There are, however, several barriers to its measurement; a major barrier may be questionnaire length. As evaluation of public health interventions becomes routine, instrument batteries are increasingly being used. Given that many elderly people are frail, it is important that batteries are as parsimonious as possible to minimise response resistance since this correlates with questionnaire length (Dillman, 1978; Yammarino et al., 1991). Additionally, there are psychometric reasons for parsimony related to the validity of measurement. These two issues suggest it is

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important to develop short measures (Pedhazur and Schmelkin, 1991). Examples include the SF-12 from the SF-36 (Ware et al., 1995; ` f from the WHOQOL-100 Ware et al., 1996), the WHOQOL-Bre (WHOQoL Group, 1996, 1998), the Hearing Participation Scale from the Glasgow Health Status Inventory (Hawthorne and Hogan, 2002), and the short form of the Social Support Questionnaire, SSQ6, from the SSQ (Sarason et al., 1987b). Although there are many published instruments measuring social isolation, these are generally long scales designed to measure multiple constructs, they may invoke response resistance because the items are negative in tone, they are embedded within other instruments, or they may have poor psychometric properties. As such their application is limited in the situations described above. There is need for a short general scale that is both user-friendly and that has excellent measurement properties. This paper describes the development of such a scale, the Friendship Scale (FS).

METHODS The data reported here are from the World Health Organization Quality of Life Groups (WHOQOL Group) WHO QOL-OLD study, aimed at measuring the quality of life (QoL) of older adults. The study involves over 20 WHOQOL Field Centres around the world. Each Field Centre undertakes a core research activity that is common. There is, however, the opportunity for Centres to develop their own research agendas; in this case measuring the social isolation of older adults.

Participants
The recruitment strategy was designed to recruit older adults across the health spectrum, since an axiom of psychometrics is that instrument development samples should be drawn from the populations in which the measure will be used. Four older adult cohorts, dened as those over 60 years, were recruited. The overall recruitment rate was 63% of those in scope; data were available for 77% of those who agreed to participate. The total number of participants was 829.

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The rst cohort was older adults living in supported accommodation, hostels or nursing homes. A research assistant asked residents to participate. Those who indicated their willingness were delivered the questionnaire package which was collected a week later, after selfcompletion. Of the 157 residents approached, 122 agreed to participate and 96 completed the questionnaire. The recruitment rate was 79% of those who agreed to participate or 61% of those were contacted. This HOS (hostel) sample comprised 12% of study participants. The second cohort comprised hospital outpatients (recruited through checking medical records for those with chronic disability) or those attending day hostel support groups (recruited through snowballing of group membership). One hundred and thirty-three cases were approached, and 78 agreed to participate. Sixty-eight questionnaires were completed. The recruitment rate of the OUT (outpatients) cohort was 51% of those contacted or 87% of those who agreed to participate. The third cohort was older veterans. Many veterans report diculties with general social relationships, although they may have close links within the veteran community. Advertisements were placed in Mufti, the Australian Returned and Servicemans League magazine, and Tapis, the Australian war widows magazine. Of the 164 responses, 130 veterans or their wives/widows participated; a response rate of 79% of responders. The MAR (magazine respondents) cohort was 16% of the study sample. To recruit a healthy community sample the Victorian electronic telephone directory was used. Cold calling of randomly selected telephone numbers identied households with an older adult. Those who agreed to participate were posted a self-complete questionnaire. Of the 1018 households with an older adult, 713 agreed to participate and 535 returned completed questionnaires; a participation rate of 75% of those within scope or 53% of all households with an older adult. The COR (community older random sample cohort) comprised 65% of study participants.

Measures
` f, questions The questionnaire package comprised the WHOQOL-Bre from the proposed FS, the 4-item version of the Geriatric Depression

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Scale (GDS, DAth et al., 1994), the Assessment of Quality of Life (AQoL) utility measure (Hawthorne et al., 1999, 2001), the SF-12 health status scale (Ware et al., 1995), socio-demographic items and a consent form. The 4-item version of the GDS (DAth et al., 1994) was designed for screening elderly patients in general practice to identify those with depression. It comprises 4 dichotomous items. The cutpoints are 1 indicating an uncertain diagnosis and 2 indicating probable depression. ` f is a QoL instrument comprising 24 items in The WHOQOL-Bre four domains: Physical (7 items), Psychological (6 items), Social (3 items) and Environment (8 items) (WHOQoL Group, 1996, 1998). Additionally, there are two global overall QoL items. All items are rated on a 5-point scale, scoring is by summation and scores are ` f has been used in presented as percentages. The WHOQOL-Bre studies of mental health and aging (Herrman et al., 2002a; Amir and Lev-Wiesel, 2003; Chan et al., 2003). The Assessment of Quality of Life (AQoL) utility instrument comprises ve dimensions: Illness, Independent Living, Social Relationships, Physical Senses and Psychological Wellbeing (Hawthorne et al., 1999, 2000). It uses the latter four for computing the utility score ranging from )0.04 (worst possible HRQoL) to 0.00 (death equivalent HRQoL) to 1.00 (full HRQoL). It has previously been used in studies of aging (Osborne et al., 2003) and mental health conditions (Goldney et al., 2000b; Herrman et al., 2002a; Hawthorne et al., 2003). The SF-12 has 12 items, which are weighted during scoring for their contribution to either physical (PCS) or mental health (MCS) (Ware et al., 1995; Ware et al., 1996). Items are concerned with the performance of particular functions. PCS and MCS scores are presented as T-scores (McCall, 1922) where the norms are 50 (sd = 10). US weights have been used. The SF-12 has been used in mental health and older adults studies (Everard et al., 2000; Taylor et al., 2000; Herrman et al., 2002b; Jackson and Burgess, 2002).

Friendship Scale items

The relationships reviewed above between social isolation and health conditions have been explained by numerous theories of social

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support, which may be grouped into three key theories: (a) that the social milieu aects responses to stress and that where there is a mismatch in social milieu t, stress may lead to health conditions (Cassel, 1976); (b) that social support provides a buer when people are in crisis, thus the absence of social support may remove this buer leading to health conditions (Cobb, 1976); and (c) attachment theories which state that childhood experiences predispose adult social network behaviour (Bowlby, 1971). Clearly, all three theories are related. Based on these theories, social isolation can be dened as living without companionship, having low levels of social contact, little social support, feeling separate from others, being an outsider, isolated and suering loneliness. This denition suggests that there are seven dimensions to the construct, and that social isolation can occur where these are transgressed. These dimensions, drawn from the literature, are: (a) an absence of sharing of feelings or being intimate with a signicant other or others (Weiss, 1974; Russell et al., 1980; Cutrona, 1986; Sherbourne and Stewart, 1991; Lugton, 1997; Hawthorne et al., 1999; Smith, 2003); (b) the (in)ability to relate to others (not just the absence of opportunity) with a particular emphasis on what it is that the relationship provides (Henderson et al., 1980; Rose et al., 2000; Lauber et al., 2004); (c) being unable to ask others for support when it is needed, perhaps due to the perception of being a burden to others (Sarason et al., 1987a; Sherbourne and Stewart, 1991; WHOQoL Group, 1998; Kissane et al., 2001); (d) having no social networks, regardless of whether these are for receiving or giving support (Sarason et al., 1987a; Lee and Robbins, 1995; Victor et al., 2000); (e) being separate or isolated from others in social settings, including being unable to perform social roles (Ware et al., 1993; Hawthorne et al., 1999; Rokach, 2000); (f) being isolated from others, whether through diculties in communication or social inadequacy (Lee and Robbins, 1995; Lugton, 1997; Victor et al., 2000); and (g) being alone or suering loneliness, including how a person perceives their position in relation to others (Russell et al., 1980; Sarason et al., 1987a; Rokach, 2000; Victor et al., 2000). Obviously, social isolation is a multidimensional construct, and each of these dimensions should be measured in a comprehensive instrument. There are numerous operationalizations of this construct, as the following few examples show. The UCLA Loneliness Scale

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measures personal and social levels of relationships (Russell, 1982; Russell et al., 1980). The Social Connectedness Scale (Lee and Robbins, 1995) measures connectedness, aliation and companionship through negative items confronting the respondent with their losses. Rather more positively, the MOS Social Support Survey (Sherbourne and Stewart, 1991) dened social support as the frequency with which companionship or assistance was available, and the short form Social Support Questionnaire dened it as those who could be counted on (Sarason et al., 1987a). The WHOQOL-100 Social domain was concerned with relationship satisfaction (WHOQoL Group, 1998). Others have focused more on nurturing, alliances and intimacy (Weiss, 1974; Russell, 1982; Russell et al., 1984; Cutrona, 1986), while the Social Relationships scale of the AQoL dened it as the performance of intimate, family and friendship roles (Hawthorne et al., 1999, 2000). These dierences (and many others can be found) suggest there are competing perspectives on the construct, including diculties in dening what should be measured. Because the construct is multidimensional, the dierent approaches suggest that its measurement may be dicult. This can be illustrated by two measures, developed 20 years apart. The Inventory of Socially Supportive Behaviours (Henderson et al., 1980) comprised 52 items for interview administration, located in 6 scales. Conrmatory factor analysis revealed that while some scales were unidimensional and reliable others were not. More recently, Rokachs work dened ve subscales of loneliness: emotional distress, social inadequacy and alienation, growth and discovery, interpersonal isolation and self-alienation. These were measured by 82 items accounting for just 36% of the variance (Rokach, 2000). Where the dimensions or subscales of social isolation are inadequately conceptualized and dened, to group them together into summated scales will almost certainly result in instruments with poor psychometric properties. For example, there is evidence that the ` f suers this problem because it Social domain of the WHOQOL-Bre consists of three disparate items measuring satisfaction with personal relationships, friendships and sex lives, where the satisfaction with the sex item is particularly dicult (Norholm and Bech, 2001; Min et al., 2002).

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Perhaps the issues above explain Bowlings conclusion made over 10 years ago but seemingly still applicable that There is currently no assessment scale which comprehensively measures the main components of social network and support with acceptable levels of reliability and validity (Bowling, 1991, p. 122). A key issue which might, perhaps, partly explain this situation relates to the perspective of measurement. The studies reviewed above may be grouped into those that provide objective assessments of social isolation based on observation of social conditions (e.g. for a review see Berkman and Glass (2000)) and those that assess it from the individuals perspective, i.e. perceived social support (e.g. see Sarason et al. (1987b)). Whilst both perspectives are valid, the position taken in this paper is that it is the subjective experience of the individual that has primacy. This perspective is consistent with the World Health Organizations commitment to the individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns (WHOQoL Group, 1993). Items from the instruments cited above were reviewed and de novo items covering each of the seven dimensions written. To ensure simplicity, item stems were made short and friendly, like those in the Social Connectedness Scale (Lee and Robbins, 1995) and the Nottingham Health Prole (Hunt et al., 1981; Hunt et al., 1985; Hunt et al., 1989). To reduce response resistance to items that may confront respondents with an awareness of their losses, items were written from the point of view of having friends and social support. To prevent acquiescent response bias (Crowne and Marlowe, 1960; Furnham and Henderson, 1982) a mixture of positive and negative items were written. During item construction, several dierent versions were constructed and considered. These were iteratively reviewed by both older adults and the authors colleagues and modied until nal versions were agreed. Regarding item responses, a Guttman-type response scale was prepared because most people do not experience isolation. To overcome end aversion the worst possible outcome (no social interaction at all) was represented by the lowest level on the response scale, recognising this implied that few people would actually endorse this level.

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Finally, the timeframe was set at 4 weeks because this provided an estimate that was stable rather than one which uctuated where a short timeframe was specied, yet not so long as to involve issues of memory recall or distortion. The nal version of the Friendship Scale (FS) is presented in the Appendix. Scoring involves reversal of items 1, 3 and 4 followed by summation across all items. The score range is 024. A high score represents social connectedness and a score of 0 complete social isolation. A computerized scoring algorithm is available from the author.

Data analysis
Data from the four cohorts described above were pooled. For reporting the psychometric properties of the FS the sample was randomly divided into half. The rst half was used as the construction sample and the second half for the conrmatory sample. Construction sample psychometric tests were principal component analysis (PCA), item-rest-of-test correlations (IRTC), and internal consistency (Cronbach a). To overcome data skew, reciprocal log transformations were used; even so, the items remained marginally skewed. Because PCA does not provide a unique mathematical model (Nunally, 1967), the analyses were repeated 20 times, sampling (with replacement) 50% of cases from the construction dataset. This provided mean estimates and 95% condence intervals. For the conrmatory analyses, AMOS (Arbuckle and Wothke, 1999) was used for a structural equation model (SEM) analysis; the criteria for t was based on the root mean square error of approximation (RMSEA < 0.05, Browne and Cudeck, 1993). Tabachnick and Fidell (2001) report that when using AMOS, discrepancies may occur in sample sizes of 200 or less with asymptotically distributionfree SEM models. In this study, the conrmatory sample was just under double this number of cases (n = 374). Partial credit item response theory (IRT) was used to determine item diculties (Andrich, 1978; Masters, 1982); this provided an estimate of the order in which the various components contributing to social isolation are progressively reported, as well as the relationship between the scale items.

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For concurrent validation tests, the full dataset was explored using correlation, Cohens q, analysis of variance (ANOVA), Fishers Exact Test and odds ratios. Data were analyzed using SPSS (SPSS, 2003), AMOS (Arbuckle and Wothke, 1999) and Conquest (Wu et al., 2000).

RESULTS Of the 829 participants, 57% were female and the mean age was 75 years (sd = 9 years). Three percent were single, 60% married or partnered, 5% divorced or separated and 32% were widowed. Nineteen percent had completed primary school, 39% high school, 16% held a trade certicate and 26% a diploma or degree. Thirtyfour percent were living at home, 52% were living at home with support (by their family or carer) and 14% were in residential accommodation (in residential care, hostel or nursing home). Twenty-two percent were working, 75% were retired or were the homemaker and 4% were unable to work because of illness or disability. Five percent were in excellent health, 19% in very good health, 31% in good health, 29% in fair health and 16% in poor health. The mean SF-12 MCS was 51.79 (sd = 9.75) suggesting participants were in good mental health, and for the PCS it was 43.40 (sd=10.43) which suggested fair physical health. Regarding quality of life, for the ` f Physical domain the mean was 65.98 (sd=18.09), WHOQOL-Bre for the Psychological domain it was 66.89 (sd=14.33), for the Social domain it was 68.55 (sd=18.15) and for the Environment domain it was 73.50 (sd=13.05). The mean AQoL utility score was 0.64 ` f and AQoL, the scores were (sd=0.26). For both the WHOQOL-Bre below population norms, suggesting a limited quality of life (Hawthorne et al. in press; Hawthorne and Osborne, 2005). For the construction sample, the PCA results showed that six of the seven items formed a unidimensional scale with mean loadings between 0.63 and 0.84. The mean for the seventh item (Item 5: Others felt they had to help me) was 0.34. The IRTCs showed a similar pattern, as shown in Table 1. These results indicated this item was not substantially contributing, so it was deleted. Following deletion, the Cronbach a was 0.81 for the remaining 6 items compared with

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0.76 for all 7 items. The 6 remaining items were numbered 16 for convenience. These 6 items were examined using the validation sample. The SEM model is presented in Figure 1, which indicates the items formed a robust model with excellent statistical properties. Partial credit IRT ascertained the order in which social losses are endorsed (IRT model statistics: v2 for parameter equality = 363.69, p < 0.01, Separation reliability = 0.99). The diculty estimates expressed in logits were: Item 1: )0.24 (weighted T = 0.1); Item 2: )0.34 ()4.8); Item 3: 0.97 (3.4); Item 4: 0.22 (0.9); Item 5: )0.07 ()2.7), and Item 6: )0.61 (constrained item). Using all cases in the study, the Spearman correlations between items ranged from 0.29 (items 1 and 5) to 0.59 (items 2 and 6). The distribution of FS scores is presented in Figure 2. This shows that 50% of participants obtained scores in the range 2024, indicating that they were not socially isolated. Other participants were spread over the FS range. For the 6 FS items, Cronbach a = 0.83. The FS was correlated with the SF-12 MCS and PCS scales, the ` f domains and AQoL dimensions (Table II). The FS WHOQOL-Bre was signicantly more correlated with the SF-12 MCS when compared with the PCS (Cohens q = 0.18, p < 0.01). For the WHO` f, the highest correlation was with the Psychological domain QOL-Bre when compared with the Physical and Environment domains (q = 0.17 and 0.11, p < 0.05, respectively). There were no other signicant dierences. For the AQoL, the highest correlation was with the Social Relationship dimension (q = 0.49 for Illness, 0.41 for Independent Living, 0.44 for Physical Senses and 0.32 for Psychological Wellbeing, p < 0.01 for all). Psychological Wellbeing was also more highly correlated with the FS than Illness (q = 0.16, p < 0.01) or Physical Senses (q = 0.12, p = 0.05). Table III presents discriminatory tests of the FS by correlates of social isolation: accommodation, work status, community involvement, wellbeing, marital status, and depression. As shown, on all measures the FS discriminated as expected. Although not reported in the table, for those living in a nursing ward (n = 5) the mean FS score was 12.22, suggesting a high level of social isolation. The table also includes an analysis by study cohort, showing there were signicant dierences, although the OUT and MAR cohorts obtained very similar scores.

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TABLE I Scale analysis of the Friendship Scale item pool: results of 20 random iterations (50% of construction cases)
Items EFA (Principal component) Mean 1 2 3 4 It has been easy to relate to others I felt isolated from other people I had someone to share my feelings with I found it easy to get in touch with others when I needed to Others felt they had to help me When with other people I felt separate from them I felt alone and friendless Eigenvalue % Variance Cronbach a 0.64 0.81 0.64 0.72 95% CIs (0.620.66) (0.800.81) (0.630.66) (0.710.74) Reliability analysis (IRTCa) Mean 0.50 0.66 0.48 0.56 95% CIs (0.480.52) (0.640.67) (0.460.49) (0.550.58)

0.34 0.74 0.83 3.36 64.53

(0.320.37) (0.730.76) (0.820.84) (3.303.42) (63.7165.34)

0.23 0.57 0.67

(0.210.25) (0.550.59) (0.660.69)

5 6

0.76

(0.750.77)

Item-rest-of-test correlation.

FS scores can be categorised into ve levels. Those who are very socially isolated will obtain scores in the range 011 because they will have endorsed at least 1 item at level 1 or lower (i.e. have reported an isolating condition most of the time or almost always). Isolated or low level social support respondents are those with scores of 12 15, which require endorsement of at least two items at or lower than level 2. Some social support refers to the range 1618, because in this range at least two items at level 3 or lower must be endorsed. The socially connected range is between 1921 because at least one item at level 3 or lower must be endorsed. The very socially connected will score within the range 2224. This requires endorsement of at least four items at level 4. A person obtaining a score in this range cannot have endorsed any item at levels 0 or 1. Based on this classication, 4% of the sample obtained scores indicating they were socially isolated, 11% were isolated with low

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Easy to relate to others 0.60 Isolated from others 0.83 Someone to share with Social Isolation 0.50 0.56 0.73 Felt separate from others 0.78 Alone and friendless Easy to get in touch

0.36

E1

0.69

E2 0.23

0.25

E3 0.34

0.31

E4

0.53

E5

0.60

E6

Figure 1. Structural equation model of the Friendship Scale items, based on validation cohort. Model shows standardised regression weights. Statistics: N = 374, model = ADF, v2 = 8.18, df = 7, p = 0.32, CFI = 0.99, RMSEA = 0.02 (95% CI: 0.000.07).

support, 17% had some support, 28% were socially connected and 40% were very socially connected. Using this scheme, for example, those who were single, separated, divorced or widowed (n = 326) were twice as likely as those who were partnered (n = 480) to report they were socially isolated or had low social support (OR: 2.16; 95% CI: 1.443.25).
250

200

Frequency

150

100

50

0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0 24.0

Friendship Scale

Figure 2. Distribution of FS scores (n = 816).

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TABLE II ` f and AQoL scales Concurrent validation with the SF-12, WHOQOL-Bre
Friendship scale N SF-12 `f WHOQOL-Bre Physical (PCS) Mental (MCS) Physical Psychological Social Environment Medication use Independent living Social relationships Physical senses Psychological wellbeing AQoL utility 808 808 808 811 798 811 784 784 794 802 802 771 rs 0.21* 0.37* 0.34* 0.48* 0.44* 0.39* 0.22* 0.29* 0.61* 0.26* 0.37* 0.53*

AQoL

*p < 0.01.

DISCUSSION Although there are many scales measuring social isolation, in general these are long stand alone instruments for interview settings, short instruments with items that are negatively worded, or they are embedded within longer instruments. Because of their length longer instruments are not particularly suitable for use in instrument batteries, while short negative scales may invoke response resistance or denial. This paper describes the development of the FS, which was designed to overcome these limitations through measuring perceived social isolation. Analysis of the item pool suggested that 6 of the 7 items formed a unidimensional scale. The 7th item measured a dierent construct and was removed; a step which improved scale reliability. The PCA proportion of explained variance was 65%. It is accepted that the proportion of explained variance should be in the vicinity of 75% for scale items to satisfactorily explain a latent concept (Pedhazur and Schmelkin, 1991; Streiner and Norman, 1995). The PCA analysis, however, may be misleading because the Pearson

TABLE III FS scores by correlates of social isolation

N sd 3.93 3.99 3.61 Friendship scores Mean 399 264 30 20.27 19.47 18.60 Scale Statisticsa

Accommodation

79

17.22

4.49

F = 15.47, df = 3,768, p < 0.01

Work status

F = 8.84, df = 2,744, p < 0.01

DEVELOPING THE FRIENDSHIP SCALE

SF-12 Item 12: Health interfered with social activities

F = 38.14, df = 4,800, p < 0.01

`f WHOQOL-Bre Item 2: Satisfaction with health status

535

At home, supported At home, unsupported Family, sheltered housing or community care Residential care/ Nursing home In the workforce Disabled/sick Retired/homemaker All the time Most of the time Some of the time A little of the time None of the time Very dissatised Fairly dissatised Neither Satised Very satised 162 30 555 20 44 128 154 459 34 107 183 380 98 19.99 16.37 19.91 15.80 15.93 17.03 19.03 20.88 16.74 17.67 18.85 20.44 21.03 3.50 5.45 3.95 4.92 5.60 4.44 3.52 3.23 4.83 4.48 4.03 3.54 3.76

F = 22.03, df = 4,797, p < 0.01

TABLE III (Continued)

N sd Friendship scores Mean Scale Statisticsa

536

Marital status

F = 16.88, df = 3,802, p < 0.01

GDS

F = 62.94, df = 2,725, p < 0.01

GRAEME HAWTHORNE

Study cohort

Single Partnered Separated/Divorced Widowed Not depressed Uncertain Probably depressed HOS hostel OUT outpatients MAR magazine COR community 27 480 39 260 596 70 62 92 67 129 528

16.37 20.34 18.00 18.83 20.43 19.21 14.13 17.37 19.28 18.78 20.26

6.01 3.80 4.30 3.91 3.45 3.80 4.83 4.29 3.73 4.64 3.73

F = 16.68, df = 3,812, p < 0.01

ANOVA, data analyses on transformed data.

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rs, upon which PCA is based, will underestimate correlations where items are skewed. Stronger evidence of model t is available from the SEM, where asymptotic models can be specied. The FS was subjected to four validity tests: SEM modelling to assess how well it tted the validation sample data, IRT to examine the order in which losses were reported, correlation with other measures, and sensitivity as measured by its ability to discriminate between known correlates of social isolation. Although it is recognised that validation is ongoing (Anastasi, 1986), instruments can be accepted as being valid where a nomological net of evidence suggests that the instrument measures what it is supposed to measure (Cronbach and Meehl, 1955). The SEM model t was excellent and the RMSEA suggested there was virtually no unexplained variance due to factors outside the model. Of interest was the nding that the three positive items were all signicantly correlated. There are two possible reasons for this. It may be due to item content, because the three negative items refer to social contact whereas the three positive items relate to being separate from others. An alternative explanation is to do with the use of positive and negative items. Although using positive and negative items is regarded as good psychometric practice to control for acquiescent response bias (Crowne and Marlowe, 1960; Furnham and Henderson, 1982), it has been shown that these cluster on dierent factors (Hawthorne and Hogan, 2002; Reiser et al., 1986). This suggests that respondents react dierently to positively and negatively worded items. If so, the SEM modication indices may have been determined by the dierent item response directions, which would be consistent with Reiser et al.s (1986) observation that on items probing social life respondents are more likely to agree with a negative item than reject a positive one. With respect to interpreting the SEM model, the standardised regression weights suggest that the pivotal items were being alone and friendless (Item 6; Figure 1), being separate from others and isolated from others (Items 5 and 2). This interpretation is consistent with the key theories of social isolation in that these items cover adult social network behaviour, the buering available through social support and the identication of poor t between an individual and their social milieu (Bowlby, 1971; Cassel, 1976; Cobb 1976). Regarding the order in which social connections are lost, the IRT diculties suggest that respondents nd it easiest to report losses in

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intimacy (item 3), getting in touch with others (item 4), feeling separate (item 5), ease in relating to others (item 1) and feeling isolated (item 2). Admitting to being alone (item 6) was the hardest item for respondents to endorse. The weighted t T-values suggested diversity among the items, more so than would be normally acceptable in a unidimensional scale. This is understandable given that the items were designed to measure dierent dimensions of social isolation; it should not be expected that the items would closely cluster on unidimensional tests. That the item diculties were spread out over the range +0.97 to )0.61 implies that they provide a broad coverage of social isolation; a feature which ensures people with all levels of social support will nd the FS relevant (Streiner and Norman, 1995). The test of concurrent validation against the SF-12 PCS and MCS, ` f domains and AQoL dimensions provides further the WHOQOL-Bre validity evidence. Regarding the AQoL Social Relationships scale, the correlation with the FS was almost double that of any other AQoL dimension, suggesting that the FS and Social scales were measuring similar concepts. The correlations with the WHOQOL` f domains were not so clear-cut. That the Friendship Scale corBre related most highly with the Psychological domain rather than the Social Relationships domain may be explained by known diculties with the sex item in this scale (Norholm and Bech, 2001; Min et al., 2002). The correlation between the FS and the sex item was r = 0.25. This suggests that satisfaction with ones sex life, particularly in older adults, may not be closely related to social isolation (e.g. consider the situation where a person has no or little sex drive or life). That the two measures of social role, the AQoL Social scale (Table II) and the SF-12 social activities question (Table III) were both highly correlated with the FS suggests that the FS is measuring social isolation in relation to how a person feels about themselves, their social role and their need for belongingness. It may also suggest that the quality of and satisfaction with relationships or social contacts is as important as the contacts themselves (Stansfeld, 1999; Fratiglioni et al., 2000). ` f PsychoThe correlations with the SF-12 MCS, WHOQOL-Bre logical domain and the dierence in FS scores by GDS classication suggest that there may be a strong mental health eect on social isolation. This is consistent with other research showing a graded relationship between mental health, particularly depression, and

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social relationships (Cobb, 1976; Thoits, 1982; Goldney et al., 2000a). An interpretation would be that self-assessment of social isolation is mediated by a persons needs and their perception that these are being met (Cobb, 1976; Thoits, 1982; Berkman and Glass, 2000; Rokach, 2000). As shown in Table 3, the FS discriminates by the known correlates of social isolation. Although these relationships do not confer construct validity in a strict sense, it is implied where scores vary as expected. These ndings are consistent with the literature regarding the correlates of low social support; viz., poor health status (Mullins et al., 1996; Ploue and Jomphe Hill, 1996), the absence of personal relationships (including marital breakdown) (Polansky, 1985; Maxwell and Coebergh, 1986; Dykstra, 1990, 1995; Mullins et al., 1996; Plopa, 1996; Gierveld, 1998), social activities, employment status and socio-economic resources (Polansky, 1985; Maxwell and Coebergh, 1986; Lewin Epstein, 1991; Mullins et al., 1996; De Jong-Gierveld and van Tilburg, 1999), and mental health status (Cobb, 1976; Thoits, 1982; Goldney et al., 2000a). Finally, based on the suggested classication of social support level, the proportions assigned to low social support (4% for very socially isolated and 11% for social isolation) were consistent with other reports of social isolation in populations (Victor et al., 2000; Baltes and Smith, 2002). The FS is subject to several caveats. Because of research constraints, no large item pool was developed and tested. Even though item construction was thorough, as described in the methods section, this omission prevented testing of multiple competing approaches to measurement. Although the psychometric properties of the FS reported in this paper are excellent, it is possible that a dierent set of items may oer better measurement. An axiom of instrument construction is that construction samples should be drawn from a heterogeneous population so that the full range of conditions will be represented. Although the samples used in this study represent a range of older adults, they may not be representative of all older adults. For example, during telephone recruitment, those who were socially isolated may have declined participation, likewise many of those living in residential care who refused to participate did so on the grounds of frailty. The precise eect of this on the study ndings is uncertain. A third caveat is that mild cognitive impairment may

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have aected the results, given the age and health status of the sample. Mini mental state examination (Folstein et al., 1975) scores were available for 72 participants. These were dichotomised at 24; scores below this suggested impairment. For all 72 cases response bias was computed (present/absent), but there was no association between impairment and response bias (Fisher Exact Test, p = 0.34) suggesting the study results were not subject to mild cognitive impairment eects. A fourth caveat is in relation to the unidimensional scale model which postulates that social isolation is a function of personal relationships; it is possible this will limit the usefulness of the scale where other constructs of social integration are required, such as making a contribution to others (Midlarsky et al., 1999). These caveats suggest that the study needs replicating in a community sample or in populations with other conditions. Given the limitations of item generation, it may also be desirable to use the items in a larger item pool to verify their properties.

CONCLUSION This study has reported on the development and preliminary validation of a short, user-friendly scale measuring perceived social isolation, the Friendship Scale. The items measure six of the seven dimensions contributing to social isolation. Its psychometric properties suggest that it has excellent internal structures and that it possesses reliability and discrimination. Although further work is needed to validate it in other populations, the results of the current study suggest that researchers may nd it particularly useful in epidemiology, population surveys or in health-related quality of life evaluation studies where a parsimonious measure of social isolation or support is needed.

ACKNOWLEDGEMENTS

I would like to thank the many researchers who have contributed to this study. My thanks go to Professor Edmund Chiu, Pippa Grifths, Dr. Barbara Murphy, Rob Winther and Dr. Kathryn Quinn

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for their assistance and support. Dr. Barbara Murphy, Claire Kelly, Marina Hocking, Karen Docherty and Kristian Futol collected the data. My thanks go to Dirk Biddle and Anne Melles for their excellent data management skills. I should like to thank the management of the William Hall Hostel, the ANZAC Hostel, the RSL Park Hostel, the Castlemaine Senior Citizens and Carer Support Groups, and the Coppin Community Hospital. I would like to thank all those participants who gave of their time to complete the long questionnaires. The WHOQOL-OLD study from which the data for this paper were drawn was funded by the University of Melbourne International Collaboration Grants program, and the WHOQOL Group through the University of Edinburgh. My position at the Australian Centre for Posttraumatic Mental Health is funded through the Australian Commonwealth Department of Veterans Aairs. Without the support of these organisations this study would not have been possible. Ethics approval was given by the ethics committees at the University of Melbourne and St Vincents Hospital, Melbourne, Australia.

APPENDIX
The Friendship Scale
During the past four weeks: *1. It has been easy to relate to others: h Almost always h Most of the time h About half the time h Occasionally h Not at all *3. I had someone to share my feelings with: h Almost always h Most of the time h About half the time h Occasionally h Not at all

2. I felt isolated from other people: h Almost always h Most of the time h About half the time h Occasionally h Not at all *4. I found it easy to get in touch with others when I needed to: h Almost always h Most of the time h About half the time h Occasionally h Not at all

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APPENDIX (Continued) During the past four weeks:

5. When with other people, I felt separate from them: h Almost always h Most of the time h About half the time h Occasionally h Not at all *These items reversed prior to scoring 6. I felt alone and friendless: h Almost always h Most of the time h About half the time h Occasionally h Not at all

REFERENCES
Amir, M. and R. Lev-Wiesel: 2003, Time does not heal all wounds: quality of life and psychological distress of people who survived the holocaust as children 55 years later, Journal of Traumatic Stress 16, pp. 295299. Anastasi, A.: 1986, Evolving concepts of test validation, Annual Review of Psychology 37, pp. 115. Andrich, D.: 1978, A rating formulation for ordered response categories, Psychometrika 43, pp. 561573. Arbuckle, J. and W. Wothke: 1999, Amos (Small Waters Corporation, Chicago). Baltes, P. B. and J. Smith: 2002, New Frontiers in the Future of Aging: From Successful Aging of the Young old to the Dilemmas of the Fourth Age (Max Plant Institute for Human Development, Berlin). Berkman, L. and T. Glass: 2000, Social Integration, Social Networks, Social Support, and Health, in L. Berkman and I. Kawachi (eds.), Social Epidemiology (Oxford University Press, Oxford), pp. 137173. Berkman, L. and L. Syme: 1979, Social networks, host resistance and mortality: a nine-year follow-up study of Alameda County residents, American Journal of Epidemiology 109, pp. 186204. Bowlby, J.: 1971, Attachment (Pelican, London). Bowling, A.: 1991, Measuring Health: A Review of Quality of Life Measurement Scales (Open University, Milton Keynes). Browne, M. W. and R. Cudeck: 1993, Alternative Ways of Assessing Model Fit, in K. A. Bollen and J. S. Long (eds.), Testing Structural Equation Models (Sage, Newbury Park), pp. 136162. Cantor, N. and C. Sanderson: 1999, Life task participation and well-being: the importance of taking part in daily life, in D. Kahneman, E. Diener and N. Schwarz (eds.), Well-Being: The Foundations of Hedonic Psychology (Russell Sage Foundation, New York), pp. 230243. Cassel, J.: 1976, The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture, American Journal of Epidemiology 104, pp. 10723. Chan, G. W., G. S. Ungvari, D. T. Shek and J. J. Leung Dagger: 2003, Hospital and community-based care for patients with chronic schizophrenia in Hong Kong

DEVELOPING THE FRIENDSHIP SCALE

543

Quality of life and its correlates, Social Psychiatry and Psychiatric Epidemiology 38, pp. 196203. Cobb, S.: 1976, Social support as a moderator of life stress, Psychosomatic Medicine 317, pp. 300314. Cronbach, J. and P. Meehl: 1955, Construct validity in psychological tests, Psychological Bulletin 52, pp. 281302. Crowne, D. and D. Marlowe: 1960, A new scale for social desirability independent of psychopathology, Journal of Counselling Psychology 24, pp. 349354. Cutrona, C.: 1986, Objective determinants of perceived social support, Journal of Personality and Social Psychology 50, pp. 349355. DAth, P., P. Katona, E. Mullan, S. Evans and C. Katona: 1994, Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions, Family Practice 11, pp. 260266. De Jong-Gierveld, J. and T. van Tilburg: 1999, Living arrangements of older adults in the Netherlands and Italy: coresidence values and behaviour and their consequences for loneliness, Journal of Cross Cultural Gerontology 14, pp. 124. Dillman, D.: 1978, Mail and Telephone Surveys: the Total Design Method (Wiley, New York). Dykstra, P.: 1990, Next of (non)kin: The Importance of Primary Relationships for Older Adults Well-Being (Swets and Zeitlinger, Lisse). Dykstra, P.: 1995, Loneliness among the never and formerly married: The importance of supportive friendships and a desire for independence, Journals of Gerontology: Series B: Psychological Sciences and Social Sciences 50B, S321S329. Ellaway, A., S. Wood and S. MacIntyre: 1999, Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations, British Journal of General Practice 49, pp. 363367. Ellis, P. and I. Hickie: 2001, What causes mental illness?, in S. Bloch and B. Singh (eds.), Foundations of Clinical Psychiatry (Melbourne University Press, Melbourne), pp. 4362. Everard, K. M., H. W. Lach, E. B. Fisher and M. C. Baum: 2000, Relationship of activity and social support to the functional health of older adults, Journal of Gerontology: Series B: Psychological Sciences and Social Sciences 55, pp. S208 S212. Farmer, I., P. Meyer, D. Ramsey, D. Go, M. Wear, D. Labarthe and M. Nichaman: 1996, Higher levels of social support predict greater survival following acute myocardial infarction: the Corpus Christi Heart Project, Behavioural Medicine 22, pp. 5966. Folstein, M., S. Folstein and P. McHugh: 1975, Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician, Journal of Psychiatric Research 12, pp. 189198. Fratiglioni, L., H. Wang, K. Ericsson, M. Maytan and B. Winblad: 2000, Inuence of social network on occurrence of dementia: a community-based longitudinal study, Lancet 355, pp. 13151319. Furnham, A. and M. Henderson: 1982, The good, the bad and the mad: response bias in self-report measures, Personality and Individual Dierences 3, pp. 311320. Gallagher, T., R. Andersen, P. Koegel and L. Gelberg: 1997, Determinants of regular source of care among homeless adults in Los Angeles, Medical Care 35, pp. 814830.

544

GRAEME HAWTHORNE

Gierveld, J.: 1998, A review of loneliness: concept and denitions, determinants and consequences, Reviews in Clinical Gerontology 8, pp. 7380. Goldney, R., L. Fisher, D. Wilson and F. Cheok: 2000a, Major depression and its associated morbidity and quality of life in a random, representative Australian community sample, Australian and New Zealand Journal of Psychiatry 34, pp. 10221029. Goldney, R. D., D. Wilson, E. Dal Grande, L. J. Fisher and A. C. McFarlane: 2000b, Suicidal ideation in a random community sample: attributable risk due to depression and psychosocial and traumatic events, Australian and New Zealand Journal of Psychiatry 34, pp. 98106. Hawthorne, G., F. Cheok, R. Goldney and L. Fisher: 2003, The excess cost of depression in South Australia: a comparative study of two methods of calculating burden, Australian and New Zealand Journal of Psychiatry 37, pp. 362373. Hawthorne, G., H. Herrman, and B. Murphy: In Press, Interpreting the WHOQOL` f: preliminary population norms and eect sizes. Social Indicators Research Bre (Accepted April 2005). Hawthorne, G. and A. Hogan: 2002, Measuring disability-specic patient benet in cochlear implant programs: developing a short form of the Glasgow Health Status Inventory, the Hearing Participation Scale, International Journal of Audiology 41, pp. 53544. Hawthorne, G. and R. Osborne: 2005, Population norms and meaningful dierences for the Assessment of Quality of Life (AQoL) measure, Australian and New Zealand Journal of Public Health 29, pp. 136142. Hawthorne, G., J. Richardson and N. A. Day: 2001, A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments, Annals of Medicine 33, pp. 358370. Hawthorne, G., J. Richardson and R. Osborne: 1999, The Assessment of Quality of Life (AQoL) instrument: a psychometric measure of health related quality of life, Quality of Life Research 8, pp. 209224. Henderson, S., P. Duncan-Jones, D. Byrne and R. Scott: 1980, Measuring social relationships: the Interview Schedule for Social Interaction, Psychological Medicine 10, pp. 723734. Herrman, H., G. Hawthorne and R. Thomas: 2002a, Quality of life assessment in people living with psychosis, Social Psychiatry and Psychiatric Epidemiology 37, pp. 510518. Herrman, H., D. L. Patrick, P. Diehr, M. L. Martin, M. Fleck, G. E. Simon and D. P. Buesching: 2002b, Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status, health service use and treatment of people with depressive symptoms, Psychological Medicine 32, pp. 889902. House, J., C. Robbins and H. Metzner: 1982, The association of social relationships and activities with mortality: prospective evidence from the Tecumseh Community Health Study, American Journal of Epidemiology 116, pp. 123140. Hunt, S., J. McEwan and S. McKenna: 1985, Measuring health status: a new tool for clinicians and epidemiologists, Journal of the Royal College of General Practitioners 35, pp. 185188. Hunt, S., S. McKenna and J. McEwen: 1989, The Nottingham Health Prole Users Manual (Galen Research & Consultancies, Manchester).

DEVELOPING THE FRIENDSHIP SCALE

545

Hunt, S., S. McKenna, J. McEwen, J. Williams and E. Papp: 1981, The Nottingham Health Prole: subjective health status and medical consultations, Social Science and Medicine 15A, pp. 221229. Jackson, H. J. and P. M. Burgess: 2002, Personality disorders in the community: results from the Australian National Survey of Mental Health and Wellbeing Part II. Relationships between personality disorder, Axis I mental disorders and physical conditions with disability and health consultations, Social Psychiatry and Psychiatric Epidemiology 37, pp. 251260. Kawachi, I., G. Colditz, A. Ascherio, E. Rimm, E. Giovannucci, M. Stampfer and W. Willett: 1996, A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA, Journal of Epidemiology and Community Health 50, pp. 245251. Kissane, D. W., D. M. Clarke and A. F. Street: 2001, Demoralization syndrome a relevant psychiatric diagnosis for palliative care, Journal of Palliative Care 17, pp. 1221. Lauber, C., C. Nordt, L. Falcato and W. Rossler: 2004, Factors inuencing social distance toward people with mental illness, Community Mental Health Journal 40, pp. 26574. Lee, R. M. and S. B. Robbins: 1995, Measuring belongingness: the Social Connectedness and the Social Assurance scales, Journal of Counseling Psychology 42, pp. 232241. Lester, D. and B. Yang: 1992, Social and economic correlates of the elderly suicide rate, Suicide and Life Threatening Behavior 22, pp. 3647. Lewin Epstein, N.: 1991, Determinants of regular source of health care in black, Mexican, Puerto Rican, and non-Hispanic white populations, Medical Care 29, pp. 543557. Lugton, J.: 1997, The nature of social support as experienced by women treated for breast cancer, Journal of Advanced Nursing 25, pp. 11841191. Masters, G.: 1982, A Rasch model for partial credit scoring, Psychometrika 47, pp. 149174. Maxwell, G. and B. Coebergh: 1986, Patterns of loneliness in a New Zealand population, Community Mental Health in New Zealand 2, pp. 4861. McCall, W. A.: 1922, How to Measure in Education (Macmillan, New York). Midlarsky, E., E. Kahana, R. Corley, R. Nemero and R. A. Schonbar: 1999, Altruistic moral judgment among older adults, International Journal of Aging and Human Development 49, pp. 2741. Min, S. K., K. I. Kim, C. I. Lee, Y. C. Jung, S. Y. Suh and D. K. Kim: 2002, Development of the Korean versions of WHO Quality of Life scale and WHOQOL-BREF, Quality of Life Research 11, pp. 593600. Mullins, L., C. Elston and S. Gutkowski: 1996, Social determinants of loneliness among older Americans, Genetic, Social, and General Psychology Monographs 122, pp. 453473. Norholm, V. and P. Bech: 2001, The WHO Quality of Life (WHOQOL) Questionnaire: Danish validation study, Nordic Journal of Psychiatry 55, pp. 229235. Nunally, J.: 1967, Psychometric Theory (McGraw Hill, New York). Osborne, R. H., G. Hawthorne, E. A. Lew and L. C. Gray: 2003, Quality of Life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) instrument and comparison with the SF-36, Journal of Clinical Epidemiology 56, pp. 138147.

546

GRAEME HAWTHORNE

Pedhazur, E. and L. Schmelkin: 1991, Measurement, Design and Analysis: An Integrated Approach (Lawrence Erlbaum, Hillsdale). Plopa, M.: 1996, Anxiety dynamics in sea isolation: family determinants, Polish Psychological Bulletin 27, pp. 359371. Ploue, L. and A. Jomphe Hill: 1996, Distressed and lonely: health and social determinants among residents in seniors housing, Journal of Clinical Geropsychology 2, pp. 5160. Polansky, N.: 1985, Determinants of loneliness among neglectful and other lowincome mothers, Journal of Social Service Research 8, pp. 115. Reiser, M., M. Wallace and K. Schuessler: 1986, Direction-of-wording eects in dichotomous social life feeling items, in N. Tuma (ed.), Sociological Methodology (Jossey-Bass, San Francisco).. Retsinas, J. and P. Garrity: 1985, Nursing home friendships, Gerontologist 25, pp. 376381. Rokach, A.: 2000, Loneliness and the life cycle, Psychological Reports 86, pp. 629642. Rose, L. E., J. Campbell and J. Kub: 2000, The role of social support and family relationships in womens responses to battering, Health Care for Women International 21, pp. 2739. Ruberman, W., E. Weinblatt, J. Goldberg and B. Chaudhary: 1984, Psychosocial inuences on mortality after myocardial infarction, New England Journal of Medicine 311, pp. 552559. Russell, D.: 1982, The measurement of loneliness, in L. Peplau and D. Perlman (eds.), Loneliness: A Sourcebook of Current Theory, Research and Therapy (John Wiley, New York), pp. 81104. Russell, D., C. Cutrona, J. Rose and K. Yurko: 1984, Social and emotional loneliness: an examination of Weisss typology of loneliness, Journal of Personality and Social Psychology 46, pp. 13131321. Russell, D., L. Peplau and C. Cutrona: 1980, The revised UCLA Loneliness Scale: concurrent and discriminant validity evidence, Journal of Personality and Social Psychology 39, pp. 472480. Sarason, B. R., E. N. Shearin, G. R. Pierce and I. G. Sarason: 1987a, Interrelations of social support measures: theoretical and practical implications, Journal of Personality and Social Psychology 52, pp. 813832. Sarason, I., B. Sarason, E. Shearin and G. Pierce: 1987b, A brief measure of social suppport: practical and theoretical implications, Journal of Social and Personal Relationships 4, pp. 497510. Scheier, L. and G. Botvin: 1996, Purpose in life, cognitive ecacy, and general deviance as determinants of drug abuse in urban black youth, Journal of Child and Adolescent Substance Abuse 5, pp. 126. Sherbourne, C. and A. Stewart: 1991, The MOS social support survey, Social Science and Medicine 32, pp. 705714. Smith, A. A.: 2003, Intimacy and family relationships of women with chronic pain, Pain Management Nursing 4, pp. 13442. SPSS, 2003, SPSS for Windows 11.5 ed. (SPSS Inc, Chicago). Stansfeld, S.: 1999, Social support and social cohesion, in M. Marmot, R. Wilkinson(eds.), Social Determinants of Health (Oxford University Press, Oxford), pp. 155178.

DEVELOPING THE FRIENDSHIP SCALE

547

Straits Troster, K., T. Patterson, S. Semple, L. Temoshok, P. Roth, J. McCutchan, J. Chandler, I. Grant and The HNRC Group: 1994, The relationship between loneliness, interpersonal competence, and immunologic status in HIV-infected men, Psychology and Health 9, pp. 205219. Streiner, D. and G. Norman: 1995, Health Measurement Scales: A Practical Guide to their Development and Use (Oxford Medical Publications, Oxford). Tabachnick, B. G. and L. S. Fidell: 2001, Using Multivariate Statistics (Harper Collins, New York). Taylor, A. W., D. H. Wilson, E. Dal Grande, D. Ben-Tovim, R. H. Elzinga, R. D. Goldney, A. C. McFarlane, F. Cheok and K. Kirke: 2000, Mental health status of the South Australian population, Australian and New Zealand Journal of Public Health 21, pp. 2034. Thoits, P.: 1982, Conceptual, methodological and theroretical problems in studying social support as a buer against life stress, Journal of Health and Social Behaviour 23, pp. 145159. Turner, R. J.: 1981, Social support as a contingency in psychological wellbeing, Journal of Health and Social Behavior 22, pp. 357367. van Oostrom, M. A., M. A. Tijhuis, J. C. Van Haes, R. Tempelaar and D. Kromhout: 1995, A measurement of social support in epidemiological research: the social experiences checklist tested in a general population in The Netherlands, Journal of Epidemiology and Community Health 49, pp. 51824. Victor, C., J. Bond, A. Bowling and S. Scambler: 2000, Growing older: The ESRC Research Programme on Extending Quality of Life: Loneliness, Social Isolation and Living Alone in Later Life. Electronic source: http://www.shef.ac.uk/uni/ projects/gop/gop21.html. Access date: 15 December 2000. Ware, J., M. Kosinski and S. Keller: 1996, A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity, Medical Care 34, pp. 220233. Ware, J., M. Kosinski and S. Keller: 1995, SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales (The Health Institute, New England Medical Center, Boston). Ware, J. E., K. K. Snow, M. Kosinski and B. Gandek: 1993, SF-36 Health Survey: Manual and Interpretation Guide (The Health Institute, New England Medical Centre, Boston). Weiss, R.: 1974, The provisions of social relationships, in Z. Rubin (ed.), Doing Unto Others (Prentice Hall, Englewood Clis), pp. 1726. WHOQoL Group: 1993, Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL), Quality of Life Research 2, pp. 153159. WHOQoL Group: 1996, WHOQOL-Bref: Introduction, Administration, Scoring and Generic Version of the Assessment (World Health Organization, Geneva). WHOQoL Group: 1998, Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychological Medicine 28, pp. 551558. Williams, R., J. Barefoot, R. Cali, T. Haney, W. Saunders, D. Pryor M. Hlatky, I. Siegler and D. Mark: 1992, Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease, Journal of the American Medical Association 267, pp. 520524.

548

GRAEME HAWTHORNE

Wu, M., R. Adams and M. Wilson: 2000, ACER Conquest: Generalised Item Response Modelling Software (ACER press, Melbourne). Yammarino, F., S. Skinner and T. Childers: 1991, Understanding mail survey response behavior: a meta-analysis, Public Opinion Quarterly 55, pp. 613639.

Australian Centre for Posttraumatic Mental Health Department of Psychiatry The University of Melbourne PO Box 5444 West Heidelberg, Victoria Australia 3081 E-mail: graemeeh@unimelb.edu.au