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Occupational restructuring by and selected psychological characteristics of older adults after the death of their spouse

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Occupational restructuring by and selected psychological characteristics of older adults after the death of their spouse

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Content INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6" x 9" black and white photographic prints are available for arty photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. A Bell & Howell Information Company 300 North Z eeb Road. Ann Arbor. M l 48106-1346 USA 313/761-4700 800/521-0600 OCCUPATIONAL RESTRUCTURING BY AND SELECTED PSYCHOLOGICAL CHARACTERISTICS OF OLDER ADULTS AFTER THE DEATH OF THEIR SPOUSE by JoAnne Wright A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy (Occupational Science) August 1995 Copyright 1995 JoAnne Wright UMI Number: 9617006 Copyright 1995 by Wright, JoAnne All rights reserved. UMI Microform 9617006 Copyright 1996, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFORNIA 90007 This dissertation, w ritten by ........................JoAnne. Wright......................................... under the direction of h&K. D issertation Committee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillm ent of re quirements fo r the degree of D O C T O R OF PH ILOSOPH Y C. • ' D ean o f G ra d u a te S tu dies Date . DISSERTATION COMMITTEE This dissertation is dedicated to Eugene Dewey Wright Ann Outzen Wright Jeffrey Warren Wright Eugene Edward Wright Zola Piffel and Art Freen Ill Acknowledgements If doing a Master's thesis is like pushing a chain up a hill, then a dissertation is like having to build the hill, forge metal into a chain and THEN push the chain up the hill. There is nothing quite like the exhilarating view at the top when you finally get there. Without the support and love of a wonderful group of people, all of this would not have happened. Although this dissertation is my work and my production, there are many hearts and hands and minds that are a part of this project. I want to express appreciation to the following people and groups: RUTH ZEMKE,the chair of my committee, for the gifts of wisdom and patience. She has been a solid and unwavering friend, colleague, and mentor through these past six years. MEMBERS OF MY COMMITTEE,— Ann Neville-Jan (who has had faith in me since our fortuitous meeting in 1986), David Peterson (for his calm spirit), Cynthia Hedricks (for her kind heart)and Thomas McNeill (for his willingness). To all of them thank you for your time, consideration, and encouragement. They were true scholars throughout the process. THE USC/AOTF CENTER FOR RESEARCH for partial funding of this research. iv THOSE WHO HAVE HAD THE VISION OF OCCUPATIONAL SCIENCE through the years and the courage to make it grow and blossom. THE USC DEPARTMENT OF OCCUPATIONAL THERAPY STAFF AND FACULTY for their support especially, ROBIN TURNER for her understanding heart. DALE LUND AND THE UNIVERSITY OF UTAH GERONTOLOGY DEPARTMENT This study couldn't have happened without their willingness to share their research. MY ASSISTANT for her dedication. PARTICIPANTS OF THIS STUDY for their generous gift of self. DEB MANDEL for her statistical calmness and all the other magic she has brought into my life. JOYCELYNN PALMER and MIKE CARLSON for their Christ-like statistical knowledge, spoken in English (sort of). And to DEBBIE CARLSON for her reminders of what really is important. THE MAGNIFICENT SEVEN that started in Bruce Hall— Jeanne Jackson, Sue Knox, Sheama Krishnagiri, Heidi Pendleton, Doris Pierce, and Loree Primeau. JEANNE JACKSON deserves special thanks. She was there strong and steady with her friendship, useful tips, and support through these past six years. She was exhausted and she made me laugh. THE STUDENTS from whom I have learned and I have taught the past four years. V As I "chewed the elephant" my personal circle of supports has been nothing short of incredible, especially during the darkest nights. DAD AND MOM for their never failing love and support. I couldn't ask for better parents, they never stop giving. JEFF, who put things into perspective (IAS) and was a wonderful computer consultant. But more importantly, a truly wonderful brother and Poogey. Sher Bear-over the miles-"Now let me ask you this"; Carolyn Snyder and our Pollyanna-whine walks; McNary, the rubber tree ant; the solitaire sunshine; the fireplace; MCI; AT&T; the e-mail gang: Deb Hazel and Janice West. TO ALL OTHERS just as dear and important but, too numerous to mention. Another group that showered me with healing strength were the men and women of the Friday night shift and the Presidency at the Los Angeles Temple. How wise the meek of the earth can be. I am also unspeakably appreciative and aware of the gifts of health, wisdom, strength, support, vision and love that I received from the other side of the veil. "They were more with us than against us", although, at times I forgot to look up . No act of love is ever wasted because we are eternal and I have been taught this over and over during the process. vi Table of Contents Dedication.................................................... ii Acknowledgements .......................................... iii List of T a b l e s ............................................. viii Abstract ..................................................... x Chapter 1: Introduction ................................... 1 Purpose of Research ..................................... 3 Design of the Study ........................................3 Research Questions ....................................... 4 Assumptions .............................................. 5 Limitations .............................................. 5 Significance of the Study .............................. 5 Chapter 2: Literature Review .............................. 8 Definitions of Grief and Bereavement .................. 9 Marriage and Bereavement ................................ 10 Two processes of spousal bereavement .............. 11 Bereavement and daily occupations .................. 12 Study of day to day life and bereavement...........13 Bereavement Studies ..................................... 13 University of Utah s t u d i e s ...........................14 Gender Differences and Bereavement ..................... 17 Personal Resources and Bereavement ..................... 18 Life Satisfaction Scale .............................. 19 Abilities and S k i l l s ..................................20 Rosenberg Self-esteem Scale ......................... 22 Health and Bereavement ................................... 23 Depression and Bereavement .............................. 24 Yesavage Depression Scale ............................ 25 Socioeconomic Status and Bereavement .................. 26 Conclusion.................................................. 26 Chapter 3: Methods........................................... 29 Research Design .......................................... 30 Participants .............................................. 31 Instrument.................................................. 3 3 Procedure .................................................3 3 Demographics .......................................... 35 Non-standardized elements from U of U study . . . .36 Standardized elements from U of U study............. 36 Occupational elements used in the questionnaire . .37 Structure of the questionnaire ..................... 38 Data Analysis ..............................................39 Vll Table of Contents (continued) Chapter 4: Results........................................... 43 Descriptive Analyses ..................................... 43 Analyses of Gender Differences ....................... 51 Analyses of Differences Of Potential & Actual Subjects 53 Comparison of Participants and the Deceased ......... 55 Research Question #1 56 Research Question #2 60 Research Question #3 67 Research Question #4 72 Chapter 5: Discussion ....................................... 78 Generalization of Results .............................. 78 The Process of G r i e f ...................................... 81 The Occupational Restructuring Process ................. 84 Occupations ................................................87 Application to Occupational Science .................. 89 Application to Occupational Therapy .................. 90 Conclusion..................................................91 References.................................................... 92 Appendix A: Participant Recruitment Materials ........... 99 Appendix B: University of Utah Study Instruments . . . 105 Time 1 Instrument ........................................105 Time 4 Instrument ........................................125 Appendix C: Comparison Between Items From Questionnaires.149 Appendix D: Research Committee Consent ................ 154 Appendix E: Questionnaire For This S t u d y ................ 156 Appendix F: Analyses of Results Tables ................ 177 Vlll List of Tables Table 1-Coping Ability and Satisfaction with Coping by Percentage of Sample (N=122) . . 46 Table 2-Distribution Yesavage Depression Scale by Percentage of Sample (N=122) 47 Table 3-Distribution on Life Satisfaction Scale (LSI-Z) by Percentage of Sample (N=122)................... 48 Table 4-Rosenberg Self-esteem Scale Scores by Percentage of Sample (N=122) 49 Table 5-Perceived Feelings About Self-esteem by Percentage of Sample (N=122) 50 Table 6-Ratings of Perceived Health by Percentage of the Sample (N=122)................................51 Table 7-Perceived Loneliness by Percentage of the Sample (N=122).........................................51 Table 8-Age of Participants and Deceased by Category by Percentage at Time of Spouses' Death (N=122) . 55 Table 9-Participation of Males and Females Participating in This Study and Those Deceased Since the First Study (N=161)........................56 Table 10-Responses to Degree of Difficulty to Cope with Death of Spouse Without Ability to Do Occupations By Percentage ......................... 57 Table 11-How New Skills or Abilities Were Learned By Percentage........................................... 61 Table 12-How Occupations Previously Handled By Spouse Which Subjects Had Not Known How To Do Were Accomplished by Percentage ....................... 65 Table 13-Freguency of Males' Responses About Most Difficult Time........................................ 68 Table 14-Freguency of Females' Responses About Most Difficult Time .................................... 72 Table 15-Intrasubject Differences of Selected Variables 73 Table 16-ANOVA Outcomes of Differences Over Measurement. P h a s e s ................................................75 ix List of Tables (continued) Table 17-Significant Intrasubject Differences Between Times of Measurement............................ 77 Table Fl-Gender Comparison Using Chi-Square ........... 177 Table F2-Gender Comparison Using t-tests .............. 179 Table F3-Comparison Of Participants and Non-Participants Using Chi-Square................................... 181 Table F4-Comparison Of Participants and Non-Participants Using t-tests........................................ 183 Table F5-Comparison of Variables for Participants and Deceased Using Chi-Square...........................184 Table F6-Comparison of Variables Between Participants and Deceased Using t-tests ..................... 186 X Abstract This descriptive study, using an Occupational Science base, focused on older adults and how they restructured their lives during an eight year period after the death of their spouse. Two distinct processes were seen to occur. The first was a normal, yet individual, grieving process that accompanies any loss; and the second, was the restructuring of the individual's occupations (daily activities that occupied their time) without the spouse. The subjects (N=122) were recruited from a group of older adults, ages 58-90, who had participated in a two-year longitudinal study done at the University of Utah. Data from three collection periods (At the time of the spouse's death, two years and eight years later) were used to look at how the participants restructured their occupations during this time period. Psychological measures of self-esteem, coping, and depression were also compared across time.. Results showed that the participants used a variety of strategies to learn the new skills or occupations as they restructured their lives. Strategies included learning by trial and error, learning from friends and relatives, paying someone else to do it or teach them and foregoing the occupation. New occupational skills (daily activities) that had to be learned, tended to follow gender specific lines. The majority believed that they had coped better than they had expected. xi Psychological measures of self-esteem, life satisfaction and coping all had a statistically significant decrease two years after the spouse's death and then a statistically significant increase eight years after the death. Depression decreased at two years then returned to a baseline level by eight years. Loneliness was a recurring theme, even though the participants felt they had coped well and were satisfied with how they had adjusted to life without their spouse. 1 Chapter 1 Introduction The death of a spouse is a major event in one's life, having many effects on the remaining spouse (Atchley, 1991; Holmes & Rahe, 1967; Lund, 1989). Many of the early studies on bereavement excluded older adults (usually those adults over 50 years of age), because it was believed that older adults were closer to death and that bereavement would not be a difficult process (Lund, 1989; Sable, 1991). Bowlby (1988) contends, however, that the loss of a significant person is difficult no matter when it happens during a lifetime. Up until about a decade ago, there were few studies that looked at spousal bereavement in the elderly. According to more recent studies, there are two related, yet distinct, processes for the older adult after the death of his or her spouse. The first process is grieving the loss of that significant person. This area has been well studied in the past 10 years (Caserta, Van Pelt, & Lund, 1989; Lund, Caserta, Dimond, & Shaffer, 1989; Norris & Murrell, 1990; Silverman & Cooperband, 1975; Rubinstein, 1986; Van Zandt, Mou, & Abbott, 1989). The second process is the restructuring of the disrupted daily occupational activities (Zautra, Reich, & Guarnaccia, 1990). This area has received less research attention, especially lacking studies that explore the restructuring of daily activities over an extended period of time after a spouse's death. 2 The death of a spouse affects the perception of all of life's experiences. There are even further changes in that perception, as the widowed person reconstructs a stable self and environment without the person who may have been a primary element of both (Zautra, Reich, & Guarnaccia, 1990). The multidimensional aspects of human bereavement include what an individual consciously thinks about, as well as aspects without conscious choice. Faletti, Gibbs, Clark, Pruchno & Berman (1989) looked at survivors, relationships, and death situation factors and their effects on the course of bereavement in older adult spouses. They suggested there is a process going on that is much more complex and dynamic than had been previously thought. There is an actual restructuring of life. The whole being is involved in the restructuring process. Every room, every situation, or event, even that which previously had been familiar, becomes a new reality with which one has to deal (Lund, Caserta, & Dimond, 1989). The death of a spouse influences a person physically, emotionally, socially and economically. New tasks need to be accomplished, new identities are formed, social attachments and connectedness are altered, new perspectives are learned and social relationships and interactions are changed (Lund, Caserta, & Dimond, 1989). Purpose of Research The purpose of this study was to look at how someone who had lost his or her spouse restructured life over almost a decade. While longitudinal studies have looked at depression, self-esteem, life satisfaction and perceived coping at the time shortly after a spouse dies, the question still remains unanswered regarding the process of restructuring one's life over a longer time than two years. Additionally, research has not focused on long term study of the occupational restructuring which has been necessary since the death of the spouse. This study was designed to do so and to determine what strategies the remaining spouse used to cope with the life changes following the death of his or her spouse. Design of the Study Using a descriptive and comparative design, this study looked at a group of people, who after having lost their spouses eight years ago, participated in a two year longitudinal study about the effect of the loss of the spouse. This two year longitudinal study was conducted through the University of Utah (U of U) starting in 1986 at the time of death of the spouses. The topics studied included: health, social support, depression, life satisfaction, perceived coping, and related demographic variables. While some of these topics remained of interest for comparison after the extended period, eight years since the death of the spouse, Occupational Science, an emerging basic science that systematically studies humans as occupational beings (Clark et al., 1991, Yerxa et al., 1989), suggested further topics to aid in understanding the restructuring of occupational routines and strategies of coping relating to occupational change after a spouse has died. It should be noted that occupations are broadly defined as "the specific 'chunks' of activity within the ongoing stream of human behavior which are named in the lexicon of culture" (Yerxa et al., 1990 p 5). Research Questions The research questions that were addressed in this study were four. Question 1: What routine occupations and daily living tasks do older people whose spouses have died perceive that they have had to restructure? Question 2: What strategies were used by the participants of this study to cope with the occupational and life changes following their spouse's death? Question 3: When did participants of this study say the most difficult time was for them after their spouse had died and why? Question 4: How did the participants change in selected psychological characteristics during an eight year period after the death of their spouse? Assumptions It was assumed that the participants will be able to comprehend the questionnaire administered to them and that they answered the questions to the best of their ability. It was also assumed that the subjects had the ability to identify and recall the coping strategies they used to cope with the life changes following their spouse's death. Limitations A limitation to generalization of this study comes from the homogeneity of the sample of subjects. They were all Caucasian, predominantly middle class, and fairly well educated people. This study can be generalized to a similar sample of older adults, but not to all, due to the variety in the older population. Significance of this Study Grief does not have an established universal process, but there are certain tendencies or commonalities that are found among those who are bereaved, such as the sense of abandonment or loneliness (Kinderknecht & Hodges, 1990). There is a need to continue studying bereavement as a naturally occurring process, one of life's many transitional experiences. Based on the framework of Occupational Science, we can learn more about how one orchestrates his or her own life experiences in the face of an uncontrollable, yet natural situation such as the death of one's spouse. We can also begin to better understand how an individual, 6 trying to make sense of the death of a spouse and dealing with the pain of loss, restructures the occupational routines that define the self. Gallagher, Thompson & Peterson (1981) and Lund (1989) have suggested that there is a need to examine multiple internal and external factors in older adults to understand the real impact of spousal loss. In addition to looking at the individual, Norris & Murrell (1990) saw a need for studies that more precisely evaluate the types of environmental demands experienced by the older adult after the death of his or her spouse. For Occupational Science, the environmental demand to take on new occupational responsibilities after the loss of a spouse is of particular interest and is an appropriate area in which to focus research energy, thus adding a unique perspective to the understanding of the bereavement process. Another significant reason this study was undertaken was to directly look at the occupational restructuring that occurs when a spouse dies. The occupational therapy research literature has looked at the restructuring of occupations after retirement and how engagement in occupations influences certain psychological measures in older adults. These studies have not directly taken into consideration the restructuring that occurs after the death of ones' spouse. In looking at older adults and their occupations or activity levels it was shown that there is a positive relationship between the level of activity or 7 occupation and the older adults' life satisfaction and morale after retirement. Gregory (1983) found that how engaged retirees were in their occupational activities was positively related to their life satisfaction, autonomy and feelings of competency during retirement. Ray & Heppe (1986) note that engaging in activity has many positive benefits that include offsetting losses in ones' social environment (worker role loss with retirement or spousal loss), maintaining morale and self worth, acquiring social role supports and positive life satisfaction. Marino-Shorn (1986) showed similar findings about high morale when the older adult maintained a balance of occupations between work, rest and leisure. Smith (1987), using the model of human occupation as a basis, looked at occupations in older adults. She found that, by engaging in activities and occupations which increased independence and life satisfaction, the older adult was better able to maintain their psychological well being. This body of literature explored the effects of occupational restructuring as it related to the older adults' life styles especially in the realm of retirement. There have been no specific studies to date that have dealt with the occupational restructuring that occurs after the death of a spouse. 8 Chapter 2: Literature Review Human beings experience the external and internal realms of life through a multidimensional process. This multidimensional process has been aptly described as orchestrating one's life through the orchestration of one's daily occupations. That is, the individual activities and skills in which one engages can be grouped or "chunked" into occupations which are then combined in a rich, meaningful way (Clark, Parham, Carlson, Frank, Jackson, Pierce, Wolfe, & Zemke, 1991; Yerxa, Clark, Frank, Jackson, Parham, Pierce, Stein & Zemke, 1990). Sometimes the individual focuses on one occupation being carried out, but more often, our daily routines are organized with several occupations sequenced together in a temporal rhythm. Human beings are not preprogrammed to act in a stimulus-response way. Rather, they are able to make conscious decisions in terms of how they will organize their life experiences, given certain constraints. These constraints include genetic makeup; physical, mental, and emotional makeup; personality traits; social and cultural constraints and environmental realities (Yerxa, et al. 1990). One of the realities humans are confronted with is the final process of life that we call death. Prior to one's own death, one must deal with the permanent loss of 9 people and things through the death of others (Gallagher, Thompson & Peterson, 1981). As a direct result of medical advances in conquering acute diseases, a better understanding and more widespread application of health standards and more prosperous living conditions, more and more people are living to old age. There certainly have always been people living into the eighth and ninth decades of life, however because of those advances, the percentage of the old has dramatically increased. Due to this phenomenon, since the beginning of the 20th century, death and the losses of significant others in death has slowly come to be thought of as an old person's experience (Atchley, 1991; Cavanaugh, 1990). Definitions of Grief and Bereavement The words bereavement and grief often are used interchangeably, as are mourning and grieving. For this study, grieving is defined as the normal reaction to loss through death. Loss is a universal experience, repeatedly encountered (Kalish 1985; Rando, 1984), which is a natural part of our existence. Grieving is a process encompassing emotions, but not just sadness or depression. It includes a whole host of emotions ranging from anxiety, to guilt, to confusion, and more (Caserta, Van Pelt, & Lund, 1989). When one is experiencing these emotions at the loss of a spouse for example, one is in the state of bereavement or grief or mourning. 10 Besides affecting emotions, bereavement or mourning reaches into every part of one's self-image. It effects a person psychologically (through feelings, thoughts, and attitudes), socially (through behaviors toward others and behavior of others toward the griever), and physically (through health and bodily symptoms) (Kastenbaum, 1987; Kearl, 1989; Rando, 1984). Marriage and Bereavement Having lived with a spouse for a number of decades, when that spouse dies, one has not only the need to deal with the loss of that significant other, but also the need to restructure the day to day experience that was once shared (Gallagher, Thompson, & Peterson, 1981; Lund, 1989). Marriage is defined as a legal relationship that has involved, at the very minimum, living together for an extended period of time with a sense of commitment to a partner (Futterman, Gallagher, Thompson & Lovett, 1990; Schell, 1990). Schell (1990) suggests that, over the passage of time, there is a shift from identifying one's partner as a love object to including the partner as a part of one's own identity. Having once been a part of a couple, the bereaved spouse maintains that relationship as part of his or her identity (Sable, 1991). The death of a spouse is consistently seen as a major stressor, requiring more readjustment than any other life event (Barnes, 1990; Birner, 1990; Gallagher, Breckenridge, Thompson, & Peterson, 11 1983; Gilewski, Farberow, Gallagher & Thompson, 1991; Lund, 1989; Sable, 1991; Van Zandt, Mou, & Abbott, 1989; Zautra, Reich and Guarnaccia, 1990). Lund, Caserta, & Dimond (1989) noted that the death of one's spouse is a multidimensional experience, influencing a person physically, emotionally, socially and economically. They continued by saying numerous aspects of one's daily life are altered and adjustments must be made. New tasks need to be accomplished, new identities are formed, social attachments and connectedness are altered, new perspectives are learned and social relationships and interactions are changed (p.3). Two processes of spousal bereavement. It has been suggested that there are two related, yet distinct processes going on in the older adult spouse who is grieving (Caserta, Van Pelt & Lund, 1989; Lund, Caserta, Dimond, & Shaffer, 1989; Norris & Murrell, 1990; Rubinstein, 1986; Silverman & Cooperband, 1975; Van Zandt, Mou, & Abbott, 1989). The first process deals with the emotional part of the loss and accepting the reality of the death. The second process is restructuring day to day life without the deceased spouse. This day to day restructuring includes the inherent changes in roles, tasks, and daily activities or occupations. The major life event of the loss of a spouse disrupts daily living patterns (Zautra, Reich & Guarnaccia, 1990). Older 12 bereaved spouses are confronted with a daily life that might be radically different from the occupational routines developed over many years of married life (Lund, 1989). Bereavement and daily occupations. For those spouses who have been a part of each other's lives for decades, there often has been a strong delineation of occupational roles, responsibilities and tasks. Over a long period of time each spouse may have become highly skilled at some roles and tasks at the expense of less skill at others that were taken care of by the spouse (Lund, Caserta, Dimond,& Shaffer, 1989). After the death of the spouse, the older bereaved adult must face new tasks he or she may never have done before. Some of these tasks might include shopping for groceries, balancing the checkbook, carrying out home repairs or yardwork (Caserta, Van Pelt & Lund, 1989). Additionally, the bereaved spouse may have relied on the deceased's skill to initiate and maintain social situations and now must learn to do so independently while dealing with the new social role of being a single adult. In a study done at the University of Utah (Lund 1989), it was found that people in the older cohorts who had lost a spouse to death often complained of being deficient in specific skills that followed traditional gender role delineation. When asked if not being able to do certain 13 tasks had made coping with the loss of their spouse more difficult, 73% of the older participants said "yes" (Lund, Caserta, Dimond & Shaffer, 1989). Study of day to day life and bereavement. Thompson, Gallagher, Cover, Gilewski & Peterson (1989) suggest that it is important to evaluate the impact of bereavement on the everyday functioning of older adults to increase knowledge of its impact on and relationship to mental health. Rubinstein (1986) studied how a day was constructed by elderly widowers. He found that "there is an important relationship between the experience of bereavement and the construction of a day. The effects of overcoming loss and successful reorganization in one's life can be found in part in an ability to go beyond the day as a 'meaningful unit'" (p 170). The men more successful at coping were able to eventually group bigger "chunks" of time as they reorganized the occupation of their routine. The general conclusion of those researchers who have focused on the day to day experience of bereavement suggest that the actual ability to complete daily occupational tasks is highly relevant to the understanding of how someone adjusts to the death of a spouse. Bereavement Studies In the past decade, there has been much more research energy devoted to the study of the older adult, the effects of spousal bereavement and bereavement as a natural process. 14 Many of the more recent studies (i.e. Dimond, Lund & Caserta, 1987; Futterman, Gallagher, Thompson,& Lovett, 1990; Gass, 1989; Lund, 1989; Lund, Dimond, Johnson, Poulton & Connelly 1985; Murrell & Himmelfarb, 1989; Norris & Murrell, 1990; Thompson, Breckenridge, Gallagher & Peterson, 1984; Zautra, Reich & Guarnaccia, 1990) have turned to a longitudinal design in an attempt to correct methodological problems and to get at the essence of older adult spousal bereavement. University of Utah studies. In the early 1980's, the University of Utah began a longitudinal study funded by the National Institute on Aging (ROl AF02193). The study was designed to "describe from a multidisciplinary perspective, the process of adjustment that follows the death of a spouse, examine factors that influence the observed outcomes, and identify potential focuses and strategies for intervention" (Lund, Caserta & Dimond; 1993, p 240). The focus areas of this study included health, social support, depression, life satisfaction, perceived coping and related demographic variables. Standardized instruments that were used included: the Neugarten Life Satisfaction Scale (Neugarten, Havinghurst & Tobin, 1961), Yesavage Depression Scale (Yesavage, Brink, Rose, Lum, Huang, Adey & Leirer, 1983), Zung Depression Scale (Zung, 1965), the Revised Texas Inventory of Grief (Faschingbauer, 1981), and the Rosenberg Self-esteem scale (Rosenberg, 1965). They used several 15 Likert scaled items and single items measuring self-esteem, health, coping, stress, loneliness and social support. There was an inventory of bereavement used, as well as a 25 item abilities and skills inventory (Lund, Caserta, Dimond, 1993; Lund, Dimond, Caserta, Johnson, Poulton, & Connelly, 1985; Lund, Redburn, Juretich & Caserta, 1989). A second study, also funded by the National Institute on Aging (ROl AG06244), was based on this first study. It had a somewhat different focus, but the same design, a prospective longitudinal design, was used. The focus of this study was to determine the effects of four different conditions of self help groups, that is professional or widow-peer led and long term or short term in facilitating the process of bereavement among recently widowed older adults as well as a control group not involved in any support group (Lund & Caserta, 1992; Lund, Caserta & Dimond, 1993). In both of the studies, bereaved spouses were sampled from four to six times over a period of 2 to 2.5 years. Participants for the first study included recently bereaved spouses over the age of 50 who were identified through the obituaries of the local newspaper (N = 192). A matching control group of nonbereaved older adults (N = 104) was also selected on the basis of sex, age, and socioeconomic area of residence. The participants were asked to complete a survey six times during the first two years of bereavement. Their mean age at the beginning of the study was 67.6 years (SD = 8.2), with a range of 50 to 93 years. They had been married an average of 39 years. The subjects for the second study (from which the sample for this author's research was obtained) which began in 1986, were recruited using the same criteria as in the earlier study. The second study's focus was specifically on the value of four different types of support groups. Of the sample of 339 people, 241 subjects were assigned to intervention condition groups and 98 were assigned to a control group. The questionnaires that were administered four times during this study were the same as in the first one, with the exception of some of the demographic variables. The survey questionnaire was administered 2 months after the death of the spouse (Tl). The second questionnaire was administered 2-6 months later (T2). The third questionnaire was administered 14-17 months after the death of the spouse (T3) and the fourth questionnaire was administered 2 years following the death of the spouse (T4). The sample consisted of 242 women (71.4%) and 97 men, ranging in age from 50 to 89 years (M = 67.5, SD = 8.5). The respondents were primarily Caucasian (98.8%) and fairly well educated (85% high school graduates) (Lund, Caserta & Dimond; 1993). Subjects from this sample were contacted by this author six years after their participation in the University of Utah's second study and asked to participate 17 in this dissertation study. Information from the University of Utah study was compared to data from this study, to further investigate change over time. The next section of the literature review will focus on some of the areas that have been mentioned as either having impact on bereavement or are a part of the grieving process. This is not an exhaustive review but rather a focused review of the areas that were studied in the University of Utah study and in this study, as well as briefly noting topics in the University of Utah study that will not be included in this study but which are of interest in examining the complex nature of bereavement and the reorchestration of one's life following the death of a spouse. This section includes a description of the standardized instruments that were used in this study. Gender Differences and Bereavement Two studies (Lund, Caserta, & Dimond, 1986; Gallagher Breckenridge, Thompson & Peterson, 1983) found almost no significant difference between men and women in terms of social and psychosocial outcomes of coping with bereavement. Men were more likely to remarry, but remarriage didn't necessarily mean the bereavement process had come to an end (Lund, 1989). For males and females, bereavement adjustment had similarities in intensity, frequency, and changes over time. Heyman & Gianturco (1973) and Van Zandt, Mou & Abbott (1989) found no gender differences in perceived mental 18 health. They also found no differences between males and females in their physical health. Coping strength did not differ between genders, however, coping styles of women were more of a mixed type combining cognitive strategies (such as self-talk, looking for purpose and using past memories) and behavioral strategies (such as keeping busy and information gathering) with more of an emphasis on the cognitively oriented, while men relied more on the behaviorally oriented strategies (Gallagher, Lovett, Hanley-Dunn and Thompson 1989; Gass, 1989) . Personal Resources and Bereavement In identifying older adults who demonstrated coping difficulties after two years of bereavement, Lund, Dimond, Johnson, Poulton, & Connelly (1985), found the strongest significant indicator was low self esteem prior to the death of their spouse. Murrell, Meeks & Walker (1991) looked at how older adults used personal resources (that is, the attributes and internal make up of the person used in dealing with a situation) for psychological adjustment. These personal resources might include temperament, reaction to other losses, personality, tolerance and locus of control. Meeks & Walker (1991) further viewed personal resources as the coping supplies necessary for maintaining psychological well being. Faced with life event stress, 19 individuals with strong personal resources cope better and their perceived distress is lower. Those older individuals with high self esteem and good health were better able to adjust to changes in their lives. Barnes (1990) found that a predictor of an individual's skills in coping with the loss of a spouse was their previous response to loss. Caserta, Lund & Dimond (1990) found that, in terms of perceived health in older adults, the level of grieving played a minimal role. However, perceived health is considered by Farnsworth, Pett, & Lund (1989) to be a valuable personal resource because of the life changes a bereaved older adult must face and it is further discussed in the section titled Health and Bereavement. It has also been suggested that a person in good health may be less socially isolated. Life satisfaction scale. A personal resource that might be a factor in coping with grief is one's satisfaction with life. One well known and often used scale to measure life satisfaction was developed by Neugarten, Havinghurst, & Tobin (1961) and is known as the Life Satisfaction Rating Instrument. It was used as part of the Kansas City Study of Adult Life and was administered as part of an interview and evaluated by the researchers. Neugarten, Havinghurst & Tobin were looking for a way to analyze psychological well being with a sufficient number of components to represent its complexity. Two scales that were later developed based 20 on the Life Satisfaction Ratings (LSR), were the Life Satisfaction Index A (LSI-A) and the Life Satisfaction Index B (LSI—B) (Wood, Wylie & Sheafor, 1969). These indices were an attempt to use the subject's own evaluation as a point of reference and were to be relatively independent of level of activity or social participation. The Life Satisfaction Index Z (LSI-Z) is a shortened version of those self-report scales (LSI-A & LSI-B). According to Wood, Wylie & Sheafor (1969), the LSI-Z is considered a useful instrument when a reasonable approximation of psychological well being is enough. The Kuder-Richardson Formula 20 Coefficient Alpha split half reliability was .79 between the LSR and the LSI-Z. The concurrent validity of the LSI-Z with LSR was r = .57 (Wood, Wylie & Sheafor, 1969). The LSI-Z was used in the University of Utah study and also was a measure in this study. Abilities and Skills. Another scale developed to measure an aspect of personal resources is The Abilities and Skills Instrument. This scale of perceived competencies was developed by the principal investigators of the University of Utah Study of bereavement in older adults from a scale used in an earlier study of older caregivers (Caserta, Connelly, Lund & Poulton, 1987). Items that were too specific to the caregiving situation (thereby making them too difficult to generalize to bereavement) were deleted 21 (Lund, Caserta, Dimond & Shaffer, 1 9 8 9 ) . The scale has 25 items that ask respondents to rate their perceived ability (1 = no abilities, 2 = some ability, and 3 = great ability) to carry out a variety of occupational skills. Factor analysis on the complete scale yielded a Cronbach alpha of . 9 2 . Following a factor analysis, these items were divided into 3 subscales. These subscales are Social and Interpersonal Skills (oc = .86), Instrumental Skills (oc = . 8 0 ) , and Resource Identification Skills (oc = . 8 3 ) . Social and Interpersonal skills include: Understanding others' communications, anticipating others' reactions, recognizing interpersonal problems, exercising self-control, expressing thought and feelings, coping with failure, adapting to changes, being assertive and maintaining a sense of humor. The Instrumental skills include: Performing and enduring physical activity, keeping the house clean, planning things in advance, using public facilities and public transportation, organizing time, concentrating and planning and cooking meals. The Resource Identification Skills subscale includes: Utilizing sources of help, identifying resources, meeting own leisure needs, setting goals objectively and doing math problems (e.g., balancing checkbook). Analyses also looked at the relationship of the three subscales and the total competency scores. The Pearson product moment correlations were positive and were 22 moderate within the three subscales (r = .64 to r = .69) and high for subscale to total score (r = .86 to r = .91) (p < .0001). The researchers found that people whose perception of their interpersonal skills was high were also likely to report having good instrumental skills and were more able to identify resources for their needs ((Lund, Caserta, Dimond & Shaffer, 1989). This instrument was also a part of this study and was used for intra subject analysis to examine change over time. Rosenberg Self-esteem Scale. Self esteem can also be considered a personal resource. The Rosenberg Self-esteem scale is a 10 item Guttman type scale (Rosenberg, 1965) developed to measure self esteem. It is well known and often used in research. It was used in the University of Utah study and in this study. The Rosenberg Self-esteem scale is easy to administer and has been used with a variety of populations and in conjunction with a variety of other measures. This scale has a reproducibility of 93% and a scalability of 73%. According to criteria established by Guttman and Menzel, these coefficients are satisfactory. This scale has a unidimensional continuum which establishes a pattern that describes levels of self-esteem. Face validity was insured by Rosenberg's use of the Guttman model and by using items which openly and directly deal with the dimension of self-esteem. 23 Rosenberg (1965) defines self-esteem as "a positive or negative attitude toward a particular object, namely self" (p 30). High self esteem, as measured by this assessment, means the person feels he or she is good enough, not that he or she is necessarily superior to others. The person feels he or she is a person of worth and respects him/herself. The person doesn't feel perfect but recognizes that he or she has limitations and expects to improve and grow. Low self esteem, as measured by this scale denotes self rejection, self dissatisfaction and self contempt. Health and Bereavement Caserta, Lund & Dimond (1990) found that the level of bereavement played a minimal role in terms of perceived health in older adults. However, perceived health is considered by Farnsworth, Pett, & Lund (1989) to be a valuable resource because of the life changes a bereaved older adult must face. It has also been suggested that a person in good health may be less socially isolated (Gass, 1989). This finding, however runs counter to the findings of Osterweis in 1985. Interestingly, Thompson, Breckenridge, Gallagher & Peterson (1984), when studying health in terms of new illnesses or worsening of pre existing conditions, found spousal bereavement to be a significant stressor. Van Zandt, Mou & Abbott (1989) summed up the research to date by saying "despite the consensus among researchers regarding the stressful nature of 24 bereavement the data on physical health deterioration in adults over the age of 60 are limited and provide conflicting results" (p 26). The University of Utah study asked several questions related to health. In this study only a single question with a Likert scale response was used to address perceived health. Depression and Bereavement In looking at the death of a spouse in a long term marriage relationship, one important area of focus concerns the relationship between depression and bereavement in the older adult. The initial time following the death of a spouse has been shown to be the most distressing time (Futterman, Gallagher, Lund, 1989; Thompson, & Lovett, 1990; Thompson, Gallagher, Cover, Gilewski & Peterson, 1989; Zisook & Shuchter, 1986). Gallagher, Breckenridge, Thompson & Peterson (1983), Lund, Caserta, & Dimond (1986) and Zisook and Shuchter (1986) concluded that there was a degree of depression associated with bereavement which gradually dissipated during the first two years. Depression in the older bereaved spouses however, did not include the lowered self-esteem often seen in clinical depression (Reich, Zautra, & Guarnaccia, 1989). The level of depression in bereaved subjects did not drop to the level of non-bereaved control subjects during the first two years and was significantly correlated with the perceived stressfulness of the event (Duran, Turner & Lund, 1989). 25 Although some bereaved spouses have difficulty dealing with the loss of their spouse, most elderly people showed a strong degree of resiliency during bereavement (Lund, Dimond, Johnson, Poulton & Connelly, 1985; Thompson, Gallagher, Cover, Gilewski & Peterson, 1989). The University of Utah study found that two years following the death of their spouse, only 18% of the bereaved individuals were identified as still having the perception of great difficulty dealing with the loss of their spouse (Lund, Dimond, Johnson, Poulton & Connelly, 1985). It is important to note that this figure corresponds with the level of depression generally seen in the elderly population (Nolen- Hoeksema, 1987). Yesavage Depression Scale. The Geriatric Depression Scale (GDS) (Yesavage, Brink, Rose, Lum, Huang, Adey, & Leirer, 1983) was developed as a screening instrument designed for an elderly population. Depression in the elderly presents itself in very different ways than in a younger population (Atchley, 1991; Clayton, 1979; Jarvik, 1976; Wells, 1979). The questions were designed with a yes/no response format and the questions were phrased so that the subject wouldn't become overly defensive or alarmed. Data from 100 items were analyzed, with 30 items correlating most highly with the total depression score (median correlation among the 30 was 0.675 ([range = 0.47- 26 0.83]) in measuring depression. These 30 items were then used in a study of 40 normal elderly people and 60 elderly people who were under treatment for depression. Internal consistency and reliability using the 30 item depression scale were reported as follows: median correlation with total score = 0.56, mean inter-item correlation = 0.36, Alpha coefficient = 0.94, and split-half reliability = 0.94. The analyses of validity of the scale as a measure of depression was highly significant (F [2,97] = 99.48, p < 0.001). The Yesavage Depression Scale was used for the University of Utah study and this study. Socioeconomic Status and Bereavement Socioeconomic status was found to have an impact on bereavement (Gass, 1989; Lund, 1989; Thompson Breckenridge, Gallagher & Thompson, 1984). Spouses who viewed income as adeguate were much less likely to demonstrate social or psychological stress than those who perceived their income as inadequate. Findings on the effect of income on the older bereaved spouse have not been consistent or as strong as expected. For an individual, socioeconomic status might be a significant part of the bereavement process, but when analyzed as aggregate data there is no strong relationship (Lund, 1989). Conclusion This study was based on a number of pertinent topics which were investigated in the University of Utah study. That study looked at gender differences, personal resources, life satisfaction, abilities and skills, self-esteem, perceived coping abilities, health, depression and social support systems. After looking at the results of the University of Utah study and reviewing other studies on older adult spousal bereavement, certain areas stood out as important to the adjustment process and the bereavement process after the loss of the spouse. These areas, which included self-esteem, depression, life satisfaction, perceived health, perceived coping abilities and abilities and skills were a main part of this study. The focus of this study was on how older adults restructure their roles, routines, and occupations in the years following the death of their spouse. In an attempt to make the survey manageable for the subjects who participated in the study, it was kept within a twenty one page limit. This was the same length as the survey used in the University of Utah study. Because of the focus on occupation, sections were added to the survey and other sections of the University of Utah survey were shortened or deleted. There is no established universal grieving process, but there are certain tendencies or commonalities that are found among those who are bereaved (Kinderknect & Hodges, 1990). There is a need to study bereavement as a naturally occurring process, one of life's many transitional experiences; composed of how an individual makes sense of 28 the death, including the pain of loss and the restructuring of one's day to day occupational activities. How one attempts to orchestrate his or her own life experiences in the face of an uncontrollable, yet natural situation such as the death of one's spouse makes that individual who he or she is and therefore is an important area research. For many it is also an important part of life. 29 Chapter 3 Methods The focus of this research was on how older spouses have restructured their daily occupations and made adaptive changes in their lives following the death of their life long mate. The literature has shown that the death of a spouse can be considered a major life event with extensive ramifications (Atchley, 1991; Cavanaugh, 1990; Lund, 1989). Longitudinal studies have documented some of the factors involved in how a person copes with the death of a spouse (Lund, 1989; Thompson, Gallagher, Cover, Gilewski, & Peterson; 1989). However, there continues to be a lack of information regarding how the remaining spouse restructures his or her life activities and occupations over a significant time period. There is also a lack of information about the widow's or widower's perception of what impact the death of a spouse has on their daily life activities. The research questions that were addressed in this study are: Question 1: What routine occupations and daily living tasks do older people whose spouses have died perceive that they have had to restructure? Question 2: What strategies were used by the participants of this study to cope with the occupational and life changes following their spouse's death? 30 Question 3: When did participants say the most difficult time was for them after their spouse had died and why? Question 4: How did the participants change in selected psychological characteristics during an eight year period after the death of their spouse? Research Design The study was a descriptive and comparative investigation of a group of people who participated in research at the University of Utah about eight years ago after the death of their spouses. It used survey research to begin to understand factors that apply to the experience of a sample of widows and widowers as they have adjusted to the loss of their spouse over an eight year period. The responses given by the participants during the initial study soon after their spouse had died and two years following, were compared to the current response and integrated in order to address the main research questions. Survey response rate needs to be considered in looking at the results of the research. Polit & Hungler (1991) suggest "a response rate greater than 60% is sufficient for most purposes, but lower response rates are common" (p. 294). They believe the risk of a serious response bias is negligible if the response rate is high. By making comparisons between the respondents and the target population on basic demographic characteristics (e.g. age, sex, and marital status) the researcher may assume an 31 absence of serious biases. This comparison was done in the original University of Utah study (Lund 1989). Participants The participants for this study were recruited from a sample of people who originally participated in a two-year longitudinal study at the University of Utah funded by the National Institute on Aging (R01 AG06244). For this original study by Lund and his colleagues, newspaper obituaries were used to identify recently bereaved spouses over the age of 50. Approximately two months following the death, guestionnaires were either hand delivered or mailed to those who had agreed to participate. The total number of people who began and participated in at least some part of the study was 339. The initial sample consisted of 242 women (71.4%) and 97 (29%) men who ranged in age from 50 to 89 years (M = 67.5 years, SD = 8.5 years). The participants in the initial phase of the study were primarily Caucasian (99%), and were fairly well educated (85% high school graduates). They were generally not employed (76%) (Lund, Caserta & Dimond, 1993). Lund's research continued through a period of two years. Of those 339 people recruited for the study, 226 people completed the full study. Of the 226 people, 168 (74%) were female and 58 (26%) were males. In the ensuing 6 years, records from the Utah State Department of Vital Statistics indicate that at least 39 (17%) of those people had died. Of these subjects, 24 (11% 32 of the total 226 people) were female and 15 (6% of the total 226 people) were male. Interestingly, when comparing the genders of the 226 subjects, separately there was a higher percentage of males who had died (26% of 58) than of females (14% of 168), in the eight years following the death of their spouse. Subtracting the 39 subjects who were deceased from the 226 possible respondents, 187 possible research participants remained. There were 17 letters returned with no other information available and therefore no way to contact those 17 people. Of these 170 possible participants, 122 filled out the questionnaire and returned it, constituting a positive response rate of 72%. There were 25 people who declined to participate or were unable to complete the survey, a 14.7% non participation rate. No letter was returned nor response received from an additional 23 potential subjects. It was assumed that they received the letter and did not wish to participate in the study. This passive refusal group made up 14% of the potential sample. The two groups of people who either actively or passively declined participation equaled 48 people (28%). The letters used for recruitment can be found in Appendix A. The group of 122 people who participated in the study was composed of 93 females (76.2%) and 29 males (23.8%). All participants were Caucasian, and they ranged in age from 58 to 90 years (M = 73.7 years, SD = 8.6 years). The mean age 33 of this sample was 6.2 years older than that of the original sample after approximately eight years. Instrument The questionnaire that was used for this study was based in part on the original test instruments used by the University of Utah study which can be found in Appendix B. Items were added to address this study's research questions related to occupation and how older adults restructured their lives after the death of their spouse. A comparison between the three instruments is located in Appendix C. Procedure The study was approved by the Institutional Review Board (IRB) of the University of Southern California following an administrative review (see Appendix D). The study was also submitted to the IRB of the University of Utah and it was determined to need no further review by that board. The potential participants were mailed a packet requesting their participation in this current project. The packet contained a letter from this researcher describing the study and inviting them to participate in the current study; a letter of support by Dale Lund, Ph.D., one of the original study's investigators; a response form and a self- addressed stamped envelope (see Appendix A). There was no financial remuneration offered to participants. Letters that were returned from the post office as undeliverable were checked for forwarding address on the 34 envelope. If a forwarding address was listed, the letter was then rexnailed to the new address. If there was no forwarding address, the last known telephone number was called in an attempt to locate a new address or information concerning the person. If the phone number was incorrect or had changed, the local phone book was checked for a possible current listing. A phone call was made to this number to ascertain if this was the correct person and to obtain a new mailing address. The letter was then sent to the correct address if the information was available. Respondents who accepted the invitation to participate were then mailed out the questionnaire with a cover sheet and a return stamped envelope (see Appendix E). Two months following the first mailed request a second letter was sent to those who had not responded to the first request either positively or negatively (see Appendix A). This second request asked the person to reconsider participating in the study and asked that they respond regardless of whether their response was positive or negative. The request again provided a form and a self-addressed stamped envelope. People who responded positively to this second request were mailed questionnaires and self-addressed stamped envelopes. Once the questionnaires had been returned a hand written thank you note was sent to each participant. In an attempt to ascertain the current status of those people who did not respond to either of the two mailings, 35 death certificate records of the Utah State Department of Vital Statistics were reviewed. The local paper's on-line computer library was also reviewed for deaths. Of those potential participants not responding to the invitation to participate, 39 deaths were confirmed. The 23 people who did not respond may also be deceased, or they may have remarried and changed their name, or they may have moved and the change of address order had expired, or they were unable or did not wish to participate. There were 17 letters returned with no more information available in spite of attempts to follow all the leads described to locate these people. Demographics. The instrument for this study included identifying questions for within participant analysis (e.g. several measures repeated over the three collection times) and questions about demographics including: gender, age, current living arrangements, number of living children and their proximity to the respondent, and perception of financial resources. Other demographic material and descriptive information, some of which was unlikely to change, was collected from the original questionnaires such as identification number, spouse's age at time of death, race, level of education, length of time married and number of marriages, religion, participant's belief in life after death, and events surrounding death of spouse. 36 Non-standardized elements retained from University of Utah study. Likert-scale questions from the University of Utah study dealing with perceived coping, satisfaction with coping, loneliness, and self-esteem since the death of the participant's spouse were retained (Caserta, Lund & Dimond, 1990; Johnson, Lund & Dimond, 1986). A Likert-scale question about perceived health was also retained. (Linn and Linn [1980] report that in an elderly population self reports of health and objective health measures are highly correlated.) There were forced choice response questions focusing on perceived support systems and grief. There were two-open ended questions asking when the participant had the most difficulty dealing with the loss of his/her spouse, and why. Standardized elements retained from University of Utah study. The standardized instruments used in the questionnaire (see Chapter 2 for greater detail about these instruments) included a 30-item geriatric depression scale with a dichotomous choice format (Yesavage, Brink, Rose, Lum, Huang, Adey & Leirer, 1983), a 10-item self-esteem scale (Rosenberg, 1965), and a life satisfaction scale (LSI- Z) with 13 Likert-type items (Wood, Wylie & Sheafor, 1969). All of these scales have been widely used and have sound psychometric properties (Lund, Caserta, Dimond & Shaffer, 1989) . 37 Additionally, a 25 item scale that identified abilities and skills was retained. For each item, the respondent was asked to decide whether he or she had no ability, some ability, or great ability to accomplish the listed skill. This scale has a high level of internal consistency (Caserta, Connelly, Lund & Poulton, 1987; Lund, Caserta, Dimond, & Shaffer, 1989). Occupational elements used in the questionnaire. Three sections of the questionnaire were not used in the original study but originated in this current study. The first section provides a list of occupations modified from a skills assessment administered in the original University of Utah study. The questionnaire asked the participant to determine the main person (prior to the death of the spouse) who was responsible for the listed activities or occupations. The second section provides the same list of activities or occupations and the participant was asked whether following his or her spouse's death, he/she already knew how to do the activity, or had to learn it, or if someone else was now responsible for this activity. In the third section of this part of the questionnaire, the participant was asked to list the three most important activities (skills or occupations) they had to learn after the death of their spouse. For each activity the participant was then asked whether not being able to accomplish this particular task had made it more difficult 38 to cope with his or her spouse's death, how they learned it, and their perception of how the new occupation or skill affected them. The final items on the questionnaire asked if there were any other aspects of the participant's daily life or routines that have significantly changed since the death of his/her spouse that have not been covered by the survey. They were also asked if they would be willing to be interviewed at a later date. Structure of the questionnaire. The questionnaire was twenty one pages long. Each section used a different color of paper in an attempt to differentiate them and vary the visual stimuli for the respondent. The length of the questionnaire was consistent with the length of the questionnaire successfully used in the University of Utah study. Large print was used as often as possible to make the questionnaire easier to read and fill out. A pilot test of the questionnaire was conducted on a small sample of five elderly widows and one widower who were in the same age range, educational level and socioeconomic status as members of the sample. The purpose of the pilot study was to determine if the questionnaire was clear and understandable and how long it took the average older person to complete it. From the pilot study it was determined the questionnaire could be completed in an average of 45 39 minutes. It was also determined that the questions were clear and understandable. Data Analysis Once the questionnaires were collected, the data were coded and entered into the computer for data analysis using the SAS® program. Following this, distributions of all study variables were examined for normality. No normalizing transformations were required for any of the variables that contributed to this study. Frequencies were run on all applicable data as well as means, minimum scores, maximum scores, and standard deviations. Categorical data were analyzed using chi-square tests. Continuous data were handled using appropriate t-tests, depending on whether the groups were equal or unequal, and general linear model analysis of variance. Because most of the sample groups were unequal, a Welch t-test was used in most cases. Because of the number of t-tests conducted, a more conservative level of significance was set at p < .01. Analysis of variance was accomplished through general linear models which take into account groups that are of unequal numbers. The specifics of how data to answer each question were analyzed are as follows. Question 1: What routine occupations and daily living tasks do older people whose spouses have died perceive that they have had to restructure? This question was answered in 40 two ways. First there was a list of occupations or skills generated by the researcher from results of the University of Utah study for each of which the participants determined who had done them prior to the death of the spouse. The occupations that had been taken care of primarily by the spouse were then scored to determine whether the participant knew how to do it, learned how to do it or had someone else do it after the death of the spouse. This question was answered further by analyzing a participant generated list of the three most important skills they had to learn after the death of their spouse. The data were categorized and frequencies and percentages were calculated for descriptive reporting. The participants were asked whether their inability to do the task listed had affected the difficulty in coping with the death of their spouse. Question 2: What strategies were used by the participants of this study to cope with the occupational and life changes following their spouse's death? The occupations from the researcher generated list which they had not known how to do at the time of their spouses death were examined to describe two strategies of coping, that is learned how to do it versus having someone else do it. Participants were asked how they had learned the new skills in the self-generated list of skills and abilities. These strategies were reported by percentages. A general linear analysis of variance was run on the Abilities and Skills 41 Instrument to look for intrasubject differences in their perceptions of their ability levels at the time of the death of the spouse, two years, and eight years after the death. Following a significant main effect, a Scheffe multiple comparison test was run to determine which intrasubject score means differed by time. Alpha was set at p < .05 for these analyses. Means were analyzed for the directionality of significant differences in the perception of the subjects7 abilities to accomplish these tasks. Question 3: When did participants say the most difficult time was for them after their spouse had died and why? This guestion was answered by analyzing the narrative responses given by participants on the guestionnaire. The responses were grouped into categories with similar themes. The freguencies were calculated for each group as well as percentages. Question 4: How did the participants change in selected psychological characteristics during an eight year period after the death of their spouse? The psychological characteristics that were measured were measures of depression, self-esteem, life satisfaction, perceived coping and abilities/skills administered at the time a person's spouse died, two years later, and eight years after the spouse had died. In analyzing the intrasubject differences a general linear model analysis of variance was used to compare the groups. In each case, following a significant 42 main effect, a Scheffe multiple comparison test was run to determine which intrasubject score means differed by time with Alpha set at .05 for these analyses. Means were analyzed for the directionality of significant differences. Chapter 4 Results The first part of this chapter will describe the participants of this study, including comparisons between gender within this group. Following this description, the sample made up of people who participated in an earlier study, through the University of Utah, will be compared to those participants of that first study who have since died. A comparison will also be made between this sample and a combined group of participants from the original study who either declined to participate in this study, were unable to participate or were not located. The sections following these descriptive and comparative analyses will present the results as they answer each of the research questions of this study. Descriptive Analyses The sample of 122 people participating in this study had a mean age of 74 years, with the youngest 58 years old and the oldest 90 years old (M = 73.7, SD = 8.6). The participants were all Caucasian. Females comprised 76% of the group and males, 24%. Religious membership was predominantly Latter-day Saint (Mormon) (78.9%), with the remainder of the subjects Protestant (9.8%), Catholic (8.1%), and other religions (3.3%). In general, they were well educated. Over 64% had attended college or trade school and the remaining 36% of the group had attended high 44 school. At the time of the death of their spouses, 71% of the group were living alone, 28% had a child or children living with them, and in a few cases, the participant lived in the child's or children's residence. Only 2% of the participants listed "Other" for their living arrangement, that is, living with either a relative or with a friend. Eight years later, 63% were living alone, 16% had remarried, 10% lived with or had children living with them and 11% had "Other" living arrangements. At the time of the death of their spouses, 94% had living children, with 91% having at least one child within 50 miles. These percentages did not significantly change in the following eight years when 94% reported living children and 88% had at least one child within a 50 mile radius. This group can further be described in terms of how their spouse died and if the surviving spouse had a belief in an after life. Death of the spouse was expected by 60% of the participants, but 40% had not expected the death. Half of the spouses' deaths were sudden while the other half were considered slow deaths. For deaths due to a long illness, more than half (56%) of the illnesses lasted 6 months or more. At the time of their spouses' deaths, 87% of the participants had a belief in an after life, 12% were uncertain and less than one percent (.8%) had no belief in an after life. 45 Interestingly, two years after the deaths of their spouses approximately half of the sample, when responding to Likert Scale questions using a 1-7 point spread, felt they had coped well living without their spouse (M = 4.4, SD = 1.6) and were satisfied (M = 4.4, SD = 1.7) with how they had coped; whereas by eight years, the majority of the sample felt they had coped with living without their spouses (M = 5.6, SD = 1.2) and were very satisfied (M = 5.7, SD = 1.4) with how they had coped (See Table 1). When asked if they had dealt better than they had expected with the grief associated with losing their spouses the majority (72%) responded positively. Financially, 76% of the sample felt their situation was comfortable, with an additional 9% stating their financial situation was more than adequate. Only 15% felt they had difficulty making ends meet. The level of depression was measured by the Yesavage Depression Scale (See Table 2). While 61% of the participants were not depressed (M = 9.6, SD = 7.5) when measured at the time of the death of their spouses, over a quarter of the sample were mildly depressed and about 1 in 10 were severely depressed. However, when measured two years following the spouses' deaths almost everyone scored in the normal range (M = 2.8, SD = 5.1). When measuring depression after eight years, the majority of the sample scored in the normal range (M = 6.2, SD = 6.1) but almost 46 20% appear to be mildly depressed. None of the sample were severely depressed when measured at year two or at year eight. Table 1 Coping Ability and Satisfaction with Coping bv Percentage of Sample fN = 1221 Perceived Ability to Cope Without Spouse Time Not Well Mid-Range Very Well 2 Years Following 37.4% 19.5% 43.1% 8 Years Following 4.3% 13.0% 82.6% Perceived Satisfaction With Ability to Cope Without Spouse Not Time Satisfied Mid-Range Satisfied 2 Years Following 36.9% 18.9% 44. 3% 8 Years Following 7.8% 9.6% 82.6% 47 Table 2 Distribution of Scores From the Yesavaae Depression Scale by Percentage of Sample fN = 122'! Time Mildly Severely Normal Depressed Depressed At Death of Spouse 61.8% 26.8% 11.4% 2 Years Following 99.1% .9% 0 8 Years Following 81.1% 18.9% 0 Life satisfaction was measured using the Neugarten Life Satisfaction Scale (LSI-Z) (See Table 3). The scores of the participants ranged from 0 to 20 (the entire possible range, with the greater the life satisfaction the higher the score). The Life Satisfaction Scale scores were combined into two categories "Very Low to Normal" (scores of 1-10) and "Normal to Very High" (scores of 11-20). At the time of the deaths of the spouses and eight years, close to 80% responded that they had normal to high life satisfaction (M = 13.7, SD= 3.8, M = 14.1, SD = 4.3, respectively). However, two years after the deaths of the spouses, the sample was almost divided in half, with 56% considering themselves to have very low to normal life satisfaction and 43% with a normal to high life satisfaction (M = 7.4, SD = 8.0) . 48 Table 3 Distribution of Scores on the Neuaarten Life Satisfaction Scale (LSI-Z1 bv Percentage of Sample (N = 1221 Very Low to Normal to Very Time Normal Life High Life Satisfaction Satisfaction At Death of Spouse 19.9% 79.6% 2 Years Following 56.1% 43.9% 8 Years Following 21.7% 78.3% Note: Very low to normal scores were 1-10 and normal to very high scores were 11-20. Self-esteem was measured at all three data collection periods using Rosenberg's 40 point Self-esteem Scale. A score of 0-12 showed low self-esteem, 13-27 medium self esteem, and 28-40 high self-esteem (See Table 4). At the time of the deaths of their spouses, over three guarters of the participants had high self-esteem (M = 31.9, SD = 4.8). Following two years the scores had changed (M = 25.6, SD = 9.3). Less than half had high self-esteem, less than half had medium self-esteem and almost 1 in 10 had low self esteem. After eight years, the scores (M = 33.7, SD = 4.2) returned to about the same level as at the time of the death of the spouse with almost everyone reporting high self esteem. 49 Table 4 Rosenberg Self-esteem Scale Scores by Percentage of Sample (N=122 ^ Time Low Medium High At Death of Spouse 0 19.5% 80.5 2 Years Following 8.9% 47 . 2% 43 .9 8 Years Following 0 4.6% 95.4 Note: Range = 0-40, Low = 0-12, Medium = 13-27, High = 28-40. The participants were asked to use a 1-7 Likert Scale to rate their current feelings about themselves. The end descriptors were Very Negative (1) and Very Positive (7). The scores are presented in Table 5. Two years after their spouses' deaths, 28% had negative feelings about themselves, 19% had neutral feelings about themselves and 43% had positive feelings about themselves. The percentage of participants with positive feelings on this scale corresponds to the 44% with high self-esteem scores on the Rosenberg Scale. By eight years, the majority (81%) again had positive feelings about themselves. The respective means and standard deviations on the Rosenberg Scale of Self-esteem were: At the death of Spouse (M = 5.3, SD = 1.2), following two years (M = 4.5, SD = 1.5), and following eight years (M = 5.7, SD = 1.3). 50 Table 5 Perceived Feelings About Self-esteem by Percentage of Sample (N = 122) Time Negative Mid-Range Positive At Death of Spouse 8.3% 17.5% 74.2% Following 2 Years 27.6% 30.1% 42.3% Following 8 Years 5.2% 13.9% 80.9% The self perceived health of participants after the deaths of their spouses was rated using a 1-7 Likert Scale. The scores were grouped, with 1-3 representing poor health, scores of 4 the middle range, and 5-7 representing excellent health (See Table 6). At both two years (M = 4.9, SD = 1.1) and eight years (M = 4.9, SD = 1.4) after the deaths of their spouses, over half of the sample perceived their health to be excellent. About a quarter of the sample (each time) felt their health was in the middle range. There was a three fold increase in the percentage of the sample that felt their health was poor between two years and eight years after spouses' deaths. Perceived loneliness was also measured by asking: How lonely, in general have you been since the death of your spouse? Responses were on a Likert Scale of 1-7 with the end descriptors Not At All Lonely (1) and Very Lonely (7). This scale was grouped into three levels like the other 51 Likert Scales in this study for Table 7. At the time of the death of the spouse, almost two-thirds of the participants considered themselves very lonely, with only 16% in the not at all lonely category. At eight years, the group was divided roughly in thirds, with about the same percentage in each category. Table 6 Ratings of Perceived Health by Percentage of the Sample (N=122 Time Poor Mid-Range Excellent After 2 Years 5.7% 25.4% 68.9% After 8 Years 15.8% 21.9% 62.3% Table 7 Perceived Loneliness by Percentage of the Sample (N = 1221 Time Not Lonely Mid-Range Very Lonely At Death of Spouse 16.0% 21.0% 63.0% 8 Yrs Following 36.8% 31.6% 31.6% Note: 2 year data not available. Analyses of Gender Differences Chi-Square statistical analyses were carried out for the categorical data to determine whether there was an association between gender and religious membership, belief in an afterlife at the time of the spouse's death and at 2 years, Living arrangements at two and eight years, remarriage, adequacy of finances, whether the spouse's death was expected and if the spouse's death was slow or sudden. T-tests were carried out for differences between genders for age, education, number of children at the time of the spouse's death and at eight years as well as the number of children within 50 miles at those same time periods, or if there was a long illness preceding the spouse's death. The following variables, perceived coping, self-esteem using a Likert Scale, self-esteem using the Rosenberg Scale, life satisfaction using the Neugarten Scale, depression using the Yesavage scale, and competencies were also analyzed at the time of the spouse's death, after two years and after eight years. Perceived heath, general loneliness and satisfaction were analyzed at the time of the spouse's death and at eight years (see Appendix F Tables FI and F2). There were differences between widows and widowers with only two of the variables. The first finding was that at the time of the death of their spouses, a higher percentage of females (93%) believed in an after life than males (68%)(X2 [2, N = 122] = 13.65, p < .001). Gender was not significantly associated with a belief in an after life at eight years. The second gender association was with living situation after two years (X2 [4, N = 69] = 18.05, p < .001) and after eight years after the deaths of their spouses (X2 [5, N = 116] = 16.43, p < .006). After two years, 77% of the females lived alone, with another 20% living in a household with their children present. However, 65% of the males lived alone, with another 30% having remarried. At eight years, 65.6% of the females were living alone and only 8.9% of the females had remarried. A quarter of the females lived with or had living with them other people (either children, relatives or friends). In comparison, only 54% of the males were living alone and more than a third of the males (39%) had remarried. Because there were only those significant associations of variables with gender on the descriptive measures as described, all male's and female's scores will be combined into one group for the analyses of data that answer the research questions unless otherwise noted. Analyses of Differences Between Potential and Actual Subject Chi-square analyses were conducted on the categorical descriptive variables and analysis of variance were conducted on continuous variables to compare participants to non-participants. The group of non-participants included those who could not be located, those who declined participation and those who were deceased. The variables included traditional demographics such as age, race, educational level, religious membership, belief in an after life. Variables also included whether the deaths of the spouses were expected or not and if the spouse was ill prior to his/her death whether it was a long or short illness. 54 Others were their living arrangements, number of children, and number of children within 50 miles. Further variables addressed how the participants perceived they had coped since the death of their spouse and how satisfied the participants were with their coping ability. Finally, participants perceived perception of self-esteem, perceived general loneliness, and perception of health since their spouses7 deaths were analyzed. Scores from the Yesavage Depression Scale, Neugarten Life Satisfaction Scale (LSI-Z), Rosenberg7s Self-esteem Scale, and the Abilities and Skills Questionnaire were also analyzed to see if there were any differences between the participants in this study and those people from the original study who did not participate in this study. From the analyses (see Appendix F: Tables F3 & F4), it is clear that the participants of this study did not significantly differ from the original group studied at the University of Utah with the exception of scores on the Yesavage Depression Scale. There was no significant difference at the time of the death of the spouses, however following two years there was a significant difference (p < .004). It should be noted that means for both groups (Participants = 2.80 ± 5.12, Non-participants = 5.25 ± 7.34) on this depression scale are still within the range of not depressed (scores range from 0-30 with the higher the score indicating more depression). 55 Comparison of Participants and the Deceased Comparisons also were made between the descriptive statistics of the people who participated in this study and a subset of those who participated in the original study but had since died (see Appendix F: Table F5 & F6). There were only two measures that showed a significant difference between the two groups. One of the differences was that of age (t = 3.21, p < .002). The people who had died since the original study were older (N = 39, M = 70.3 ± 8.1) than those who lived (N = 122, M = 65.6 ± 7.9) to participate in this study (See Table 8). Table 8 Age of Participants and Deceased bv Category by Percentage At Time of Spouses' Death (N = 161) Group 50-65 Yrs Old 66-75 Yrs Old 76-90 Yrs Old Participants 49.5% 40.7% 9.76% Deceased 25.6% 41.0% 33.3% A significantly higher percentage of males died sometime during the eight years after their spouses' death (35%) than the 20% of the females who died (See Table 9). This may be an artifact, reflecting potential difficulty in locating 56 females who may have remarried and changed their names thus being difficult to locate in the death records. The second significant difference between those who participated and those who were deceased (p < .01) was on the scores of the Yesavage Depression Scale following two years (See Appendix F: Table F5). As was the case in the comparison between the participants and the non participants, (Participants M = 2.80 ± 5.13 and Deceased M = 5.53 ± 7.92), were within the not depressed range. There was no significant difference for any of the other variables. Table 9 Percent of Males and Females Participating in This Study and Those Deceased Since the First Study (N = 161t Group Male Female Participant 65.1% 79.8% Deceased 34.9% 20.2% Research Question #1 What routine occupations and daily living tasks do older people whose spouses have died perceive that they have had to restructure? To understand the effect of the necessary restructuring of their routine occupations the participants of the study were asked to list up to 3 new important skills 57 or activities they had to learn after their spouse died. They were asked to check from one to six responses about how learning this new skill or task had affected them. The frequency of all the responses was totaled and then percentages were figured for each of the six areas. The responses indicated that learning a new skill or activity helped them to be more independent (31%), helped them feel better about themselves (27%), helped to keep busy (16%), helped to deal better with the loss of their spouse (14%), to get along better with others (7%), and other factors (5%). Table 10 Responses to Degree of Difficulty To Cope With Death of Spouse Without Ability to Do Occupations Bv Percentage Responses Males Females Total A lot more difficult 7.8% 21.8% 18.9% Somewhat more difficult 41.2% 32.0% 33.9% A little bit more difficult 27.5% 20.3% 21.8% Hasn't made it more difficult 23 .5% 25.9% 25.4% Total Percentages 100.0 100.0 100.0 The participants were also asked whether not being able to do the ability or skill they had learned had made it more difficult to cope with their spouses' deaths. Table 10 represents these results. Over half of the women found that 58 without being able to do those tasks, it was somewhat or a lot more difficult. For the men, less than ten percent felt not having a certain skill or ability made it a lot more difficult. Two thirds of the males thought it made it somewhat or a little bit more difficult. About a quarter of both males and females felt their inability did not make it more difficult. There was a wide range of important tasks that had been handled by the spouse prior to his or her death that had been learned after the death of their spouses as a part of the restructuring process. These responses came from the three most important skills or activities question and will be described by gender grouping. For the males (total number of responses = 57), the type of skills or activities that the highest percentage of males had to learn can be grouped into a number of areas. The largest area consisted of a combination of tasks that could be described as domestic chores (54%). These included taking care of the house, learning to cook or cook better, learning to do the laundry and learning to mend or sew. The next group were recreational activities (18%). These were engaged in to fill time, to learn a new hobby or to socialize. Learning to live alone as a new task was reported by 9%. Personal skills, such as learning to be patient, becoming more social, avoiding idleness, planning time, gift shopping or learning to meet new people were listed by 10%. Financial 59 and legal matters and other miscellaneous items made up the final 9%. In the case of the females, the types of skills or activities (total number of responses = 231) were divided into a larger number of groups. This is consistent with the number of tasks they reported their spouses doing before his death. The task groupings that were the same for males and females, although the percentages were very different, were domestic chores (3% for females), recreational activities (27%), personal skills 24%, and financial or legal matters (17%). The domestic chores most listed were to learn to cook simpler or smaller meals. Other areas in which females had learned new skills were volunteering (3%); gardening, yard work or outside maintenance (6%), home maintenance including winterizing and repairs (14%), and automobile care from maintenance to purchasing (14%). Interestingly, 2% had to either learn to run the business or return to work and 2% had listed learning to use computers. Some of the computer learning was to increase job market ability and for some it was a part of recreational learning. Returning to work, was for some, a financial necessity, where with others it was a way to restructure their day. A 77 year old female stated, "[I] found out by myself that just because I'm now elderly doesn't mean that I have to sit around by myself and listen to my hair turn gray. So! I got involved at the Senior 60 Center and got myself a job in occupational therapy in a nursing home." In each of the categories there was a wide range of responses. For recreational skills, many of these females learned new hobbies such as tole painting or genealogical research, one or two returned to a college or university and one received a Masters degree. In the personal category were responses such as "feel better about myself", "Learning to make major decisions by myself", "learning not to feel like a fifth wheel", "writing weekly to children and grandchildren" or "learning to cope with failing health alone". Home maintenance and outside maintenance were two of types of activities mentioned freguently. This maintenance ranged from simple things such as learning to change the furnace filter or lawn mowing to major items such as completely winterizing a home. Car care and maintenance was mentioned in 14% of the female responses. The range was from learning to fill the gas tank or where to go for service to buying a new car. There were a few subjects who had to learn how to use public transportation after the death of their husbands (See Table 12). Research Question #2 What strategies were used by the participant of this study to cope with the occupational and life changes following their spouse's death? Table 11 summarizes the 61 responses from when the participants were asked how the they learned the new skills or abilities they had listed. More than half of the males had learned by trial and error, as compared to less than half of the females. More females (39%) were helped by either a friend or relative than males (22%). Between ten and fifteen percent of both gender group paid someone to teach them the new skill. Table 11 How New Skills or Abilities Were Learned By Percentage Response Male Female Total Trial and error by self 66.7% 41.5% 46.4% Helped to learn by friend 5.9% 14.6% 12.9% Helped to learn by relative 15.6% 24.1% 22.4% Helped to learn by paying 9.8% 13.2% 12.6% Other 2.0% 6.6% 5.7% Total 100% 100% 100% From a generated list, the subjects were asked who, prior to the spouse's death, had taken care of each particular task or occupation. The occupations that were done by the spouse prior to his or her death were then analyzed to determine how the remaining spouse had taken care of it after the death (See Table 12). The items in Table 12 have been arranged by which gender primarily listed the skill as one their spouse had 62 previously taken care of prior to his or her death. The first nine occupations were those with which more males had to begin to deal. The next eleven occupations were mixed although all of the occupations were listed by a greater number of females. The final fourteen occupations were ones that females had exclusively reported that their spouse had done prior to his death. In looking at the occupations where more males had to assume responsibility after the death of their spouses, it is assumed that those who already knew how to accomplish the task or had the skill used that knowledge. If the subject didn't know how to do it, the person either learned how to or had someone else do it, Of the first nine items, more than 10 males listed six of them as tasks they assumed. Of these six occupations approximately three-quarters of the males learned how to do them rather than have someone else do them. The actual percentages were cooking (75%), cleaning (71%), laundry (80%), mending (63%), and maintaining general nutrition and proper diet (71%). Analyzing the occupations that the females exclusively had assumed after the death of their spouses was more complicated. These tasks can be grouped into three main categories; those being household maintenance, legal and transportation related. The eight tasks in the category of home maintenance were doing minor plumbing, doing minor electrical repair, general use of tools (wrenches, pliers, 63 etc.)/ winterizing the home, locating where to turn the electricity, water and gas on and off, doing general lawn care and gardening, general maintenance of the outside, and clearing snow from sidewalks and driveways. For most of the occupations, over three quarters of the females had someone else take care of it. The exceptions were general use of tools, where it was an even split of learning how and having someone else do it; doing minor electrical repairs where 100% of the females learned how to do this; and finally locating where to turn electricity, water, and gas on and off with 79% learning how to accomplish this. There were three items under the legal category, that is selecting a lawyer, transferring car and house titles and general legal issues. Eighty-five percent of the females learned how to select a lawyer, 79% learned how to transfer titles and 63% of the females learned to take care of general legal issues. The transportation category covered tasks such as filling the gas tank (with those who did not know how to 68% learned), and knowing when and where to service the car (71% learning how). The only item that the majority (76%) had someone else do was changing the oil and checking the tire pressure. The largest area where both males and females had to assume new skills was finances. Within this area were the skills of allocating financial resources as well as 64 organizing and maintaining files; balancing a check book; paying bills; filing insurance, Medicare/Medicaid, Social Security claims & tax forms; and setting up wills and estates. With all of these tasks the majority of both males and females learned how to do these things rather than have someone else take care of it. The other item that was shared by males and females was identifying resources in the community related to transportation. The males that had not been responsible for this prior to the death of their spouses let someone else figure this out. The females, in comparison, learned this skill. It should be noted that the males perceived themselves as knowing how to take care of more occupations from the presented list than females. Care should be taken in assuming the women were more helpless than the men. This list was very outward task oriented and is only the beginning of studying occupations that needed to be assumed after the death of a spouse. 65 Table 12 How Occupations Previously Handled By Spouse Which Subjects Had Not Known How To Do Were Accomplished Bv Percentage Legend: LH = Learned how, SE = Done by someone else either gratis or paid. For clarity the Knew how Category that was mentioned was not included in the table. Occupations N Male LH % SE % N Female LH % SE % Cooking 12 75 25 0 0 0 Cleaning 7 71 29 0 0 0 Laundry 10 80 20 1 0 100 Mending 11 64 36 0 0 0 Ironing 10 60 40 0 0 0 Family/Friends 2 50 50 0 0 0 Soc Activ. 2 100 0 0 0 0 Nutrit./Diet 7 71 29 1 100 0 Groc.Shopping 6 83 17 1 0 100 Organ/finance 4 100 0 8 88 12 Checkbook 4 100 0 10 80 20 Pay bills 3 100 0 8 88 12 Insurance 1 100 0 15 67 33 Wills/Estate 0 0 0 8 50 50 Medications 0 0 0 1 100 0 Education 1 100 0 2 50 50 Social interests 1 100 0 1 100 0 Hobbies 1 100 0 2 50 50 Fin resources 2 100 0 13 85 15 Transfer title 1 0 01 13 85 15 66 Table 12 (continued) Plumbing 0 0 0 56 18 82 Electrical 0 0 0 50 100 0 Tool use 0 0 0 41 49 51 Winterize 0 0 0 47 21 79 On/Off Gas, H20 0 0 0 38 79 21 Yardwork 0 0 0 21 24 76 Outside Mainten 0 0 0 35 31 69 Snow removal 0 0 0 34 6 94 Lawyer 0 0 0 13 85 15 Legal matters 0 0 0 16 63 37 Fill up car 0 0 0 31 68 32 Check Oil/Tire 0 0 0 51 24 76 Service car 0 0 0 38 71 29 ID other trans 0 0 0 29 79 21 Another way the occupational and life changing strate tfere analyzed was through the Abilities and Skills Instrument that was developed at the University of Utah. This tool was used at all three times of data collection was considered to be a scale of perceived competency to carry out specific skills or tasks. These skills and tasks could be considered to be the components of occupations. The rating scale was 1 = no ability, 2 = some ability and 3 = great ability. As was reported in Table 12, at the time of the spouses7 deaths the mean score was 57.0 + 7.9, two years the mean had significantly dropped to 54.8 ± 10.3, and at eight years it had significantly risen to 57.7 + 8.1. This 67 level of perceived competency was back to a level similar to that which was first recorded. The results from the Abilities and Skills Instrument are more fully described under Research Question #4. Research Question #3 When did the participants say the most difficult time was for them after their spouse had died and why? A number of different questions were asked to answer this research question. The first question was when the subjects had experienced the most difficulty dealing with the loss of their spouse. The responses covered a wide range, some of the responses were actual time periods, either months or years, whereas some of the participants looked more in terms of specific events or time markers. Most of the males responded to this question, (See Table 13) that the most difficult time was somewhere between the time their wife's death to more than two years later (73%). Some reported that it is still difficult to deal with the loss of their spouse (12%). Evenings were another difficult time that was mentioned (12%). A few males said that the difficult time in dealing with losing one's spouse was related events such as her birthday or an anniversary (8%). 68 Table 13 Frequency of Males' Responses About Most Difficult Time Descriptor_____________________________________Freq of Response At the time of her death 3 First three months 2 First six months 4 First year 2 First year and a half 3 First two years plus 5 Still difficult (Continuous) 3 Evenings 3 Event related 2 TOTAL 27 They were also asked why the time they had mentioned was a difficult one for dealing with their loss. Again the responses were varied, however they can be grouped into 3 categories. Those reasons were: missing their spouse and their times together, event specific difficulties, and regrets. The majority of responses had to do with missing their spouse and learning to adjust to life without her there. A 74 year old male's comments reflected the feelings of many of the men when he reported: "I missed her, her companionship, her cheerful self, her help and counsel. It was just plain lonely— very vacant." Another commented that "...it was like losing part of me." In learning to adjust to a life without his spouse, a 75 year old man stated; "[it 69 was difficult] because I retired the following month as we had planned, and I did everything just as we had planned to do it, only alone." A few males responded that there were certain specific events that made life without their spouse more difficult such as "the 9th anniversary of her death". Two of the subjects mentioned that they had regrets of things they had done or not done while their spouse was alive that made losing their spouse difficult. The females, who constituted a larger sample size than males, expressed similar times of most difficulty of dealing with losing their spouses, although they mentioned a couple of other categories (See Table 14). The females responses that were grouped as Intermittent included responses that the most difficult time was two or three or even five years after the death of their spouses. One female stated that the most difficult time was the first year and then the third year, while another stated it was the second and fifth years that were most difficult. Yet another female stated that the most difficult time was four years into her second marriage. Event related responses from the females regarding the most difficult time to deal with the loss of their spouse ranged from anniversaries and birthdays or family events to events when problems arose with household maintenance, decision making, when there were family difficulties or when their health started to fail. Anticipatory has reference to a couple of the females who 70 stated the most difficult time was actually before the death of their husband as they watched him die a slow painful death. When the females were asked to respond as to why these various times had been difficult, their grouped responses fell into the same categories as the males, namely, missing their husband and their times together, event specific difficulties and regrets. In addition to these three, there were also responses in the categories of readjusting to life and handling problems, anticipatory, and other. The females talked about being lonely and about missing their husband's companionship. A 68 year old female put it this way: "There was not a partner to discuss options, feelings, or needs". Another female stated: "There was no one to wait on". Event specific difficulties were varied and very individualized although there was a couple of threads of similarity running throughout the responses in this category. One of those threads was that of evenings being a very difficult time to deal with the death of their spouse. Another thread was mentioned concerning social events where there were other couples. The females were much more apt to mention difficulty in the area of handling problems that arose and to the adjustment they had to make without their spouse in regard to these life adjustments. One sixty-one year old female stated, "Because of illness of a child I realized I had decisions to make alone without 71 being able to have a companion for emotional, physical and financial support." Other life adjustments came in the form of household maintenance as well as financial resource management. A telling statement by an eighty-two year old female was: "House basement flooded, car trouble refrigerator and freezer broke...everything went wrong and he always took care of this type of problem". There were a couple of females who had regrets following the deaths of their spouses about how they would have changed their marriages and what they would have done differently. The responses grouped in the anticipatory again related to the most difficult time being before the spouse died, while he was suffering a long illness. One female said "The poor man was in such agony from the cancer I was relieved when the suffering ended." A response in the Other category had to do with the anger one female felt because her husband had committed suicide. The other interesting response in this category was made by a 60 year old female who stated it was most difficult because of her husband's mother and father who couldn't accept their son's death. She was very close to them and had to help them a lot. Even when stating why the time they had chosen was the most difficult, several of them also mentioned that they had a wonderful social support system of friends or family that helped them deal with the death of their spouse and that they knew they had to go on no matter what. 72 Table 14 Frequency of Females7 Responses About Most Difficult Time Descriptor______________________________________Freq of Response At the time of his death 9 First three months 4 First six months 6 First year 17 First year and a half 1 First two years plus 9 First four years 2 Still difficult (Continuous) 2 Evenings 4 Event related 24 Anticipatory (prior to death because of his illness) 2 Intermittent, but not specific event related 12 TOTAL 92 Research Question #4 What are the differences between the results of measures of depression, self-esteem, life satisfaction, perceived coping and abilities/skills administered at the time a person's spouse died, two years later, and eight years after the spouse had died? When comparing measures of perceived coping, depression, self-esteem, life satisfaction and perceived competency of abilities and skills across the three time periods, all of the measures showed significant 73 intrasubject differences over time. The number of subjects, the mean, and the standard deviation between the three times can be noted in Table 15. If time of death were to be considered a baseline all scores decreased at two years and then returned to slightly above baseline with the exception of depression. Table 15 Variable N M SD Coping (Likert) Range = 1-7 At death 119 5.5 1.2 2 Years Following 122 4.4 1.6 8 Years Following 114 5.6 1.2 Depression (Yesavage) Range = 0-30 At Death 122 9.5 7.5 2 Years Following 122 2.8 6.2 8 Years Following 114 6.2 6.1 Self Esteem (Rosenberg) Range = 0-40 At Death 122 31.9 4.9 2 Years Following 122 25.7 9.3 8 Years Following 107 33.6 4.2 Self Esteem (Likert) Range = 1-7 At Death 119 5.3 1.2 2 Years Following 122 4.5 1.5 8 Years Following 113 5.7 1.2 74 Table 15 (continued) Variable______________________________ N_________ M________ SD Life Satisfaction (Neugarten) Range = 0-20 At Death 117 13.8 3.8 2 Years Following 122 7.4 8.0 8 Years Following 114 14.0 4.3 Competencies (Abilities & Skills) Range = 25-75 At Death 122 57.0 7.9 2 Years Following 122 54.8 10.3 8 Years Following 115 57.7 8.1 In intrasubject comparisons, the variables of perceived coping since the death of one's spouse, depression (measured by the Yesavage Depression Scale), self-esteem (measured by the Rosenberg Self-esteem Scale and a Likert scale of self esteem) , life satisfaction (measured on the Neugarten Scale) all showed a significant difference over time as shown in Table 16). The competency scores from the Abilities and Skills Instrument also showed a significant intrasubject difference at the p < .01 level. In each case following the significant main effect, a multiple comparison test (Scheffe) was run to determine which intrasubject score means significantly differed from which other score means by time. Alpha was set at .05 for these comparisons. Time 1(T1) is defined as at the time of the spouse's death, Time 2 (T2) is defined as 2 years following the spouse's death, and Time 3 (T3) is defined as eight years following the spouse's death. Table 17 summarizes the results of these tests. Table 16 ANOVA Outcomes of Differences Over Measurement Phases For Selected Variables Variable: Copina Source df SS MS F p-value ID 121 330.30 2.73 2.73 .0001 Time 2 112.38 56.19 41.11 .0001 Error 232 317.12 1.37 Variable: Deoression (Yesavacrel Source df SS MS F p-value ID 121 9081.96 75.06 3 .41 .0001 Time 2 2766.20 1383.10 62.87 .0001 Error 235 5169.96 21.10 Variable: Self'-esteem fRosenberal Source df SS MS F p-value ID 121 7414.56 61.28 1.75 .0002 Time 2 4286.44 2143.22 61.19 .0001 Error 228 7985.39 35.02 Variable: Self--esteem (Likert} Source df SS MS F p-value ID 121 360.77 2.98 2.79 .0001 Time 2 92.98 46.49 43 .45 .0001 Error 231 317.12 1.37 76 Table 16 (continued) Variable: Life Satisfaction (Neugarten LSI-Z) Source df SS MS p-value ID 121 5861.23 48.44 1.94 .0001 Time 2 3441.09 1720.54 68.96 .0001 Error 230 5738.74 24.95 Variable: Comoetencies (Abilities & Skills') Source df SS MS F o-value ID 121 16016.65 132.83 2.65 .0001 Time 2 520.04 260.02 5.21 .0061 Error 235 11737.63 49.95 For all the measures, there was a significant difference between the score at the time one's spouse died and at two years. There was also a difference in each between the two year scores and the scores at eight years. If Time 1 were to be considered a base line of sorts, all of the means dropped at Time 2 and then returned to close to base line at Time 3 (See Table 15). There were only two variables, self-esteem and depression reported on a Likert Scale, which also showed a significant difference between Time 1 and Time 3. The mean self-esteem at Time 3 was higher than for Time 1. All means were within the mid to high range of the scores. The mean for depression at Time 3 was not as great as for Time 1. Interestingly, depression significantly decreased (by virtue of lower scores) when 77 measured at two years and then there was a significant increase in the score at eight years. None of the mean scores for depression were in the severely depressed range. Table 17 Significant Intrasubiect Differences Between Times of Measurement. Variable_____________ T1 - T2_________T1 - T3_________T2 - T3 Coping *** *** (5.5, 4.4) (4.4, 5.6) Depression *** *** *** (9.5, 2.8) (9.5, 6.2) (2.8, 6.2) Self-esteem (RS) *** *** (31.9, 25.7) (25.7, 33.6) Self-esteem (Likert) *** *** *** (5.3, 4.5) (5.3, 5.7) (4.5, 5.7) Life Satisfaction *** *** (13.8, 7.4) (7.4, 14.0) Competencies *** *** (57.0, 54.8) (54.8, 57.7) Note: *** = significance between stated phases at p < .05 level. Means in parentheses to show directionality. 78 Chapter 5 Discussion A unique opportunity presented itself for the study of this group of elderly widows and widowers who had been willing to participate in a two-year longitudinal study that started at the time their spouses died eight years ago. Of the original 226 older adults who had completed the two year study, 122 were willing and able to participate again in research that studied several of the same variables, but which went further, to look at how they had restructured their occupations since the death of their spouse. Generalization of Results The University of Utah study was conducted about the same time as three other studies in the United States, one in Los Angeles, one in Miami and another in rural Nebraska (Lund, 1989). All of these studies were prospective in nature, as the participants moved through the first few years after the loss of a spouse, providing great accuracy, reliability and richness to the data. There was considerable variation among the three groups of research participants, but when the studies were considered, their findings were remarkably similar (Lund, 1989), validating the ability to generalize from the Utah sample to a broader and more varied population. 79 To further validate the ability to generalize the University of Utah study, the researchers contacted people who had refused to participate in the study. Demographically, those who had refused to participate were not significantly different from the people who participated. Further, when the non-participants and the participants of this current study were compared, the only significant difference found was their scores on the Depression scale (p < .004). It should be noted that, even with this statistically significant difference, the means of both groups were still within the normal range. That is, with possible scores ranging from 0-30 (with 30 being most depressed), the participants scores, (M = 2.80) and non participants scores, (M= 5.12) would not represent actual depression. Taking these factors into account, there is a strong case that this study can be generalized to a large subset of the older United States population. This subset can be described as Caucasians who are living independently in the community and have some financial security. This group might be considered an exemplary group who have survived the death of their spouse and have gone on to successfully restructure their lives and occupations. Because of the complexity of human beings, at this time there doesn't appear to be a way to effectively study those who may have died, partly as a result of their spouse's death. There are certainly a myriad of anecdotes that would 80 suggest that people die from broken hearts, or that for some, the will to live is significantly decreased when a spouse dies. Because of the mind-body connection, depression can certainly reduce well being or induce fatality. One deceased subject's daughter called to say that, "Mamma never really got over Daddy's death, she died of a broken heart." This is an area in which new methodologies could be developed to further our understanding. However, the study of those who survive the death of their spouse and go on to successfully restructure their lives is equally important. It is exciting to note there are recently a number of studies that have been done that have focused on the early period of bereavement, usually the first two years (Barnes, 1990; Birner, 1990; Faletti et al., 1989; Futterman et al., 1990; Gallagher, Breckenridge, Thompson, & Peterson, 1983; Gilewski, Farberow, Gallagher & Thompson, 1991; Lund, 1989; Lund, Caserta & Dimond, 1989; Sable, 1991; Van Zandt, Mou, & Abbott, 1989; Zautra, Reich and Guarnaccia, 1990). Our knowledge base has increased and there is more understanding about this natural process. This study has provided more knowledge in this area, especially in the longer term changes in life situation that go beyond the first few years of acute grief. There is only one other group of widows and widowers that has been followed for at least eight years to look at 81 particular longer term effects (McCrae & Costa, 1993). The group included participants ranging in age from 25 to 74 years. One point McCrae & Costa (1993) made, that was substantiated in this study, was that although it seems counterintuitive, there does not appear to be any major long time enduring effect on psychosocial functioning in older men or women after the death of the spouse. This does not mean that the death of a spouse isn't a difficult process to deal with and that the early years after the death of a spouse aren't a struggle. Any type of loss reguires physical and emotional energy to deal with that loss and the more important the relationship of whomever dies, the more energy is required. Most participants of this study said the most difficult time period after the death of their spouse was sometime during the first two years. The Process of Grief Before considering some of the occupational changes and choices, the process of grief should be considered. Grieving is an interesting, very complex process. While it is certainly very individual, grieving also has recognizable patterns across individuals. Elizabeth Kubler-Ross described the general pattern of loss (Kubler-Ross, 1970). It is crucial to remember that the pattern is general. An analogy to this can be found in the process of breathing. All human beings breathe, but some people breathe rapidly, some deeply, some erratically. Each individual is somewhat 82 different, but each has their a unique pattern. Even within this individual pattern, a person's breathing adapts to the situation. As examples, when exercising, more air is required than if one is at rest or reading a book; or if someone used to breathing sea level air goes to a mountain top, they must change their patterns of breathing to cope with less oxygen in the ambient air. Grieving is similar, in that each person has a certain response to loss such as a death. There is also a response to the intensity and the process that occurs depending on the situation and the environment. Current literature suggests at least a two year acute grieving period is typical after the loss of a significant other. The tasks associated with grieving revolve around restructuring one's life and redefining the meaning of one's life. Then, even when one's life has been restructured and new routines are in place, that person must continue to live that life without their spouse. In this study, loneliness was a strong recurring theme. It was mentioned over and over in all of the survey sections that were open ended as well as on the Likert scale of loneliness. Even after eight years, about a third of the sample considered themselves very lonely, with a third somewhat lonely and the remaining third as not really lonely. Sable (1991)suggested that having once been a part of a couple, the bereaved spouse maintains that relationship as part of his or her identity . 83 This could explain why loneliness was a strong thread running through the responses. Looking at psychological measures of the participants over time (the time of the death of the spouse, two years and eight years after the death of the spouse) it is important to remember that the measures are a sample of an ongoing process, a type of still frame view during the viewing of a video. The psychological measures of life satisfaction and perceived coping did not reflect significant intrasubject differences between the measurement at the time of the spouse's death and at eight years. The mean score at the time of death and the mean score after eight years were about the same. However, there was a significant decrease in life satisfaction and perceived coping between the measured responses at the time of the spouse's death and the measurement taken at two years. There was, then, a significant increase from the two year measurement to the eight year measurement. These results might suggest that the widow(er) hadn't quite realized the full impact of the death of their spouse at the time it occurred, that at two years they were still in a restructuring process, but that by eight years they had returned to a more typical state of being. Although the measure of Skills and Abilities in this study wasn't really a psychological measure, response patterns followed the same pattern as the life satisfaction and perceived coping, 84 perhaps reflecting the effect of psychological factors upon self evaluation of skills and abilities. The measure of depression followed a pattern of a statistically significant decrease from the baseline in depression at two years and then a statistically significant increase to a level that still was statistically significantly lower than the original measurement. The mean scores at all three times however, stayed in the range of not depressed. The highest level of depression (at the time of the spouse's death) may be related to the dissolving of normal routines and the shock and uncertainty of the future that can occur even though life satisfaction and perceived coping were still within a normal to high range. The Occupational Restructuring Process With the passage of time, understanding the reality of the loss naturally occurs. That is redefining the lost relationship and life style changes reinforce to the widow(er) that the spouse really is gone. One of the participants in the study described it this way: "At first I was in a fog, it just didn't seem real. Slowly I realized that he wasn't coming back and I had to get on with my life. It took a long time to do that. There were so many things to take care of all alone." This study showed that, for the majority of the participants, the first few years were the hardest for dealing with the death of a spouse. Particular events, such as birthdays or anniversaries, or situations 85 where problems had arisen (serious illness in children, appliances breaking down) could also bring back the sense of loss because of the increased awareness that their partner (someone who had become a part of them) was no longer there to share in the experience. There are some people who never really get over the death of their spouse, even though they restructure their lives. Part of the spousal grieving process is for the living spouse to redefine the relationship (Gilewski, et al., 1991; Lund, 1989, McCrae & Costa, 1993). The deceased spouse is no longer directly involved, but memories and shared past experiences continue to keep that spouse an indirect part of the living spouse. The widow(er) is involved in the daily routine of life, but there is something missing for which they continue to make adjustments. The current study looked at some of those life style effects and at occupational adaptive strategies that an older group of widows and widowers used in restructuring their lives after the death of their spouse. Due to the paucity of research and literature on the restructuring of occupations and on the effects after almost a decade, this study should be viewed as a significant beginning exploration into those areas. Much more research needs to be done to look at the complexities of life over a long period of time after the death of a spouse. 86 Daily living consists of "weaving an entire gamut of occupations into a pattern (Yerxa et al. 1989 p. 8). When a spouse has died, the daily routine of life has been dramatically changed. Routines and habits, in essence, define who we are. Because of the dramatic change in occupational patterns and patterns of interaction with the person with whom one was living, many habits no longer seem to exist or seem relevant and the definition of self may need reconstruction. New habits need to be developed as well as new routines. There is a need to find new ways to accomplish the occupations that the spouse previously handled. The range of occupations or skills that the participants of this study considered important to learn after the death of their spouses was broad. Some of the participants had to learn basic modern day survival occupations such as home and car maintenance, or financial and legal competencies, or something as simple as how to fix a meal. For others, the most important occupations were those that helped them fill days with purposeful activities or were engaged in to fill social needs. Because the majority of these participants were retired, they had a lot of autonomy in their decisions of how to fill their day. When a spouse had been responsible for certain tasks or occupations, and now the responsibility fell to the survivor, there were a variety of ways to accomplish those tasks. Sometimes the participant already 87 knew how to accomplish the task and so were able to take over the task without difficulty. Sometimes the widow(er) had to learn how to do the task. A large part of the sample believed that not knowing how to do certain things that had previously been done by their spouse made the grieving process more difficult. Learning to do those tasks made life more difficult or challenging for some, for others, it provided a perceived opportunity for growth (Lund, 1989). Other situations were managed by having someone else take care of the task. Factors that contributed to the decision about whether to do a task or have someone else do it for them were the health of the participant or their functional level of independence. The restructuring caused the participants to rethink many situations that had been dealt with almost unconsciously. Occupations Most of the occupations that had to be learned as part of the restructuring fell along historically gender typical lines. Men had to assume household duties and some of the financial and legal responsibilities their wives had taken care of and women had to be more involved in the outside home or yard maintenance and the maintenance of the car. Some women also had to now deal with the financial and legal responsibilities. Again, there was considerable variety in the new tasks that different individuals had to develop. The specific tasks learned are important to look at, but, 88 what might be even more important is the idea that the orchestration of life was now the responsibility of one person rather than a shared experience of two. Each couple had divided the responsibilities in a way unique to that relationship and the way the remaining spouse now chose to carry on was just as unique to that person. This study showed that there were differences in the number of occupations that had to be learned, with the women as a group listing more than the men. For any one individual there was usually a main type of occupation grouping that was more important for that person to learn. For some, the important tasks were of a maintenance type such as car or home. For others it was more relational, such as finding new groups of friends or social activities. There is a further need to explore through qualitative research or in depth interviews the intrinsic meaning of the occupational restructuring process in combination with what types of occupations were learned. Many of the participants, through narrative comments, showed an attitude of resiliency in handling the challenging life event changes that were brought about as a result of the spouse's death. One might look to the fact that this particular group is a part of a cohort that endured the Great Depression. The survivors of this time period have often been described as very resourceful and adaptive in facing life's difficulties because of the skills in adapting 89 they developed out of necessity during that time. Studying subseguent cohorts as they reach this stage in their lives may provide interesting comparisons to this group. Application to Occupational Science This study has added to the knowledge of how, as occupational beings, widows and widowers restructure their lives after the death of their spouse. This study, along with others (Lund et al.,1993; McCrae & Costa, 1993)has also focused on some of the internal aspects of engaging in occupations such as self-esteem and life satisfaction. It has shown that the majority of participants have found ways to restructure their daily routines and to continue finding meaning in the occupations in which they engage. This group, for the most part, has been shown to be very resilient to life's challenges. Age does not stop them from trying to master their environment. This study is, in essence, a thumbnail description of some of the long term effects of coping with the death of one's spouse. Research, involving interviews designed to explore in more depth the physical, psychological, social, cultural, and spiritual demands and resources that reconstructing occupations requires, needs to be done in an attempt to further the work that has been started here (Lund, 1989; Lund et al., 1993; McCrae & Costa, 1993). The culture which one is a part of helps define who he or she is, therefore, more research needs to be done with other cultural groups and cross- 90 cultural studies need to designed. On going research also needs to be done in the area of older adult spousal bereavement and occupational restructuring so that comparisons between cohorts can be drawn. This study has been a beginning for an important area of research. General knowledge about spousal bereavement among older adults is considered still in its infancy. Focusing on how, as occupational beings, widows and widowers have faced the death of their spouse and how they have orchestrated their lives and restructured their occupations has added important information that goes beyond just the social or psychological aspects. It begins to lay the foundation for further research in an area that in the future, will affect a huge segment of the population. Application to Occupational Therapy The practitioners in the field of occupational therapy need to be aware of the new occupations, tasks and skills with which an older person might need assistance as he or she restructures life following the death of a spouse. The development of a post bereavement screening for occupational therapists to administer might help to facilitate an increased awareness of their need to learn to deal with new skills. This would be useful in a well elderly population as well as a population who had some type of health limitation or disability. 91 Conclusion In conclusion, it has been shown that there are, indeed, two process that occur when a spouse dies. First, the process of grieving which is a normal reaction whenever a significant loss occurs in someone's life and second the process of occupational restructuring and learning how to live without someone who has become a part of your very being must occur. The open ended responses from the participants of this study substantiate Schell's idea (1990) that, over the passage of time, there is a shift from seeing one's partner as a love object to perceiving the partner as a part of one's own identity. 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International Aging and Human Development, 23 (3), 161-173. Sable, P. (1991). Attachment, loss of spouse and grief in elderly adults. Omega, 23 (2), 129-142. Schell, B.J. (1990). Whom God has joined. Psychotherapy and the Widowed Patient, 157-165. Silverman, P.R. & Cooperband, A. (1975). On widowhood: Mutual help and the elderly widow. Journal of Geriatric Psychiatry, 8, 9-27. Smith, H. (1987). Mastery and achievement: Guidelines using clinical problem solving with depressed elderly clients. Occupational Therapy in Mental Health 8, 35-46. Thompson, L.W., Breckenridge, J.N., Gallagher, D.& Peterson, J. (1984). Effects of bereavement on self-perceptions of health in elderly widows and widowers. Journal of Gerontology, 39 (3), 309-314. Thompson, L.W., Gallagher, D., Cover, H., Gilewski, M. & Peterson, J. (1989). Effects of bereavement on symptoms of psychopathology in older men and women. In D.A. Lund (Ed.), Older bereaved spouses: Research with practical applications. New York: Hemisphere Publishing Corporation. Van Zandt, S., Mou, R. & Abbott, D. (1989). Mental and physical health of rural bereaved and nonbereaved elders: A longitudinal study. In D.A. Lund (Ed.), Older bereaved spouses: Research with practical applications. New York: Hemisphere Publishing Corporation. Wells, C.E. (1979). Pseudodementia. American Journal of Psychiatry 136, 895-900. 98 Wood, V. , Wylie, M.L. & Sheafor, B (1969). An analysis of a short self-report measure of life satisfaction: Correlation with rater judgements. Journal of Gerontology 24, (4) 465-469. Yerxa, E.J., Clark, F., Frank, G., Jackson, J., Parham, D., Pierce, D., Stein, C.& Zemke, R. (1989). An introduction to occupational science: A foundation for occupational therapy in the 21st century. Occupational Therapy in Health Care, 6 (4), 1-17. Yesavage, J.A., Brink, T.L., Rose, R.L., Lum, 0., Huang, V., Adey, M., Leirer, V.O. (1983). Development and validation of a geriatric depression screening: A preliminary report. Journal of Psychiatric Research 17, 37-49. Zautra, A.J., Reich, J.W. & Guarnaccia, C. (1990). Some everyday life consequences of disability and bereavement for older adults. Journal of Personality and Social Psychology, 59 (3), 550-561. Zisook, S. & Shuchter, S. (1986). The first 4 years of widowhood. American Journal of Psychiatry, 136, 282-294. Appendix A: Participant Recruitment Materials 99 I P \K I ’M IN H ' I u ’T U P \ \|. I ||[;k \i- n N o v e m b e r 2 3 , 1 994 D e a r T h a n k y o u s o m uch f o r y o u r p r o m p t r e p l y t o t h e s t u d y r am c o n d u c t i n g . T h e r e s p o n s e f r o m t h e g r o u p h a s b e e n o v e r w h e l m i n g a n d I v e r y m uch a p p r e c i a t e y o u r w i l l i n g n e s s t o t a k e t i m e o u t o f y o u r s c h e d u l e . I r e a l i z e t h a t t h e s u r v e y w a s q u i t e l e n g t h y , b u t i t n e e d e d t o b e s i n c e t h i s r e s e a r c h i s s o i m p o r t a n t . I am v e r y e m b a r r a s s e d t o a s k y o u r h e l p o n c e a g a i n , e s p e c i a l l y a t t h i s b u s y t i m e o f y e a r . U n f o r t u n a t e l y when t h e q u e s t i o n n a i r e s w e r e c o m p i l e d a v e r y i m p o r t a n t s c a l e was i n a d v e r t e n t l y l e f t o u t . I f I c o u l d i m p o s e o n y o u o n e l a s t t i m e ( I p r o m i s e t h i s r e a l l y i s t h e l a s t t i m e ! ! ! ) . X w o u l d a p p r e c i a t e i t i f y o u w o u l d f i l l o u t t h e e n c l o s e d s e t o f t e n q u e s t i o n s a n d r e t u r n i t t o me i n t h e e n c l o s e d e n v e l o p e . I n f i l l i n g o u t t h e q u e s t i o n s a n s w e r w i t h t h e f i r s t t h o u g h t t h a t c o m e s t o m i n d . I t s h o u l d t a k e l e s s t h a n 10 m i n u t e s t o f i l l t h i s o u t . I f y o u h a v e a n y q u e s t i o n s y o u m ay c o n t a c t me a t 8 0 1 - 4 8 5 - 8 6 5 3 . T h e s e r e s p o n s e s a l o n g w i t h a l l t h e o t h e r i n f o r m a t i o n w i l l b e k e p t c o n f i d e n t i a l . I h o p e t h a t y o u r h o l i d a y s e a s o n w i l l b e a p l e a s a n t o n e . A g a i n t h a n k y o u v e r y v e r y m u c h ! ! ! ! S i n c e r e l y , J o W r i g h t MA, OTR B e r e a v e m e n t S t u d y F o l l o w Up G e r o n t o l o g y C e n t e r U n i v e r s i t y o f U t a h 316 C o l l e g e o f N u r s i n g 25 S o u t h M e d i c a l D r i v e S a l t L a k e C i t y , UT 8 4 1 1 2 1 NTV ERSITY O F S O L T H E R N C A L IF O R N IA '-III A L C A Z A R S T R E E T . C IIP U > . L O S A N G E L E S . C A L IF O R N IA "H01.1 100 UnivM ity G e r o n to lo g y C e n t e r o f UTAH O c t o b e r 1 7 , 1994 D e a r I t h a s b e e n n e a r l y s e v e n y e a r s s i n c e y o u c o m p l e t e d y o u r p a r t i c i p a t i o n i n a r e s e a r c h p r o j e c t t h a t we d i d a t t h e U n i v e r s i t y o f U t a h G e r o n t o l o g y C e n t e r . T h e p r o j e c t e x a m i n e d t h e w ay p e o p l e c o p e a n d a d j u s t t h e i r l i v e s a f t e r t h e y e x p e r i e n c e t h e d e a t h o f t h e i r s p o u s e . We l e a r n e d a g r e a t d e a l f r o m t h a t p r o j e c t a n d h a v e s h a r e d o u r f i n d i n g s w i t h o t h e r p r o f e s s i o n a l s . T h a t k n o w l e d g e h a s h e l p e d m any p r o f e s s i o n a l s t o o f f e r b e t t e r a n d m o r e e f f e c t i v e s e r v i c e s t o w id o w s a n d w i d o w e r s . T h a n k y o u f o r l e t t i n g u s l e a r n fr o m y o u r s t r e s s f u l e x p e r i e n c e s . I am now t r y i n g t o h e l p a r e s e a r c h e r , J o W r i g h t MA, OTR, a t t h e U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a who i s s t u d y i n g t h e w a y s t h a t p e o p l e l e a r n new s k i l l s a n d how t h e i r r o u t i n e s h a v e c h a n g e d i n t h e y e a r s s i n c e t h e i r s p o u s e ' s d e a t h . T h i s i s a u n i q u e o p p o r t u n i t y f o r h e r t o s t u d y t h e g r o u p y o u w e r e a p a r t o f s e v e n y e a r s a g o . By s t u d y i n g t h i s s a m e g r o u p s e v e r a l y e a r s a f t e r t h e d e a t h o f t h e i r s p o u s e s , we h a v e a c h a n c e t o s e e so m e o f t h e l o n g r a n g e e f f e c t s o f t h i s e x p e r i e n c e . T h e r e i s v e r y l i t t l e r e s e a r c h t o d a t e i n t h i s a r e a . You a r e v e r y i m p o r t a n t t o t h i s p r o j e c t . I h o p e t h a t y o u m i g h t b e w i l l i n g t o h e l p a g a i n w i t h t h i s new p r o j e c t . P l e a s e r e a d t h e e n c l o s e d l e t t e r f r o m t h e r e s e a r c h e r a t t h e U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a . H e r l e t t e r w i l l e x p l a i n t h e p u r p o s e o f t h e s t u d y a n d w h a t s h e w o u l d l i k e t o a s k y o u t o do t o h e l p i n f u r t h e r i n g t h e r e s e a r c h i n t h i s a r e a . T h a n k y o u f o r y o u r p r e v i o u s h e l p . B e s t w i s h e s f o r t h e f u t u r e . S i n c e r e l y , D a l e A. L u n d , P h . D . D i r e c t o r a n d P r o f e s s o r J 5 S o u in Medic.il D riv e ;(lb C o lle u e m N u rsm a sa lt L a k e u i v I t a h *41 I-’ m n i i FAX < m h 11 101 I I’ \!\ I Mf- M < )l i) ( ( t P \ fl< )\ M. TIIHR M 1' ) O c t o b e r 1 7 , 1994 fE23V' . u s e ; D e a r S e v e r a l y e a r s a g o y o u w e r e k i n d e n o u g h t o h a v e b e e n a p a r t i c i p a n t i n a s t u d y c o n d u c t e d b y t h e U n i v e r s i t y o f U t a h G e r o n t o l o g y D e p a r t m e n t . T h i s s t u d y i s w e l l k now n i n s e v e r a l d i f f e r e n t f i e l d s a n d h a s a d d e d a l o t t o t h e k n o w l e d g e b a s e we h a v e a b o u t o l d e r a d u l t s p o u s a l b e r e a v e m e n t . T h e s t u d y h a s p r o v e n v e r y u s e f u l t o p r o f e s s i o n a l s a n d n o n p r o f e s s i o n a l i n h e l p i n g o t h e r s who h a v e l o s t t h e i r s p o u s e s t o d e a t h . X h a v e p e r s o n a l l y u s e d t h i s k n o w l e d g e i n my own p r a c t i c e . I am now a d o c t o r a l c a n d i d a t e a n d f a c u l t y m e m b e r a t t h e U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a . F o r my r e s e a r c h I w o u l d l i k e t o s t u d y t h e sam e g r o u p , w h i c h i n c l u d e s y o u , t h a t w a s s t u d i e d a p p r o x i m a t e l y s e v e n y e a r s a g o . B e c a u s e o f y o u a n d t h e o t h e r s who h a v e w i l l i n g l y p a r t i c i p a t e d i n g r i e f s t u d i e s we k n o w m o r e a b o u t t h e p r o c e s s e s o n e g o e s t h r o u g h a t t h e t i m e t h e i r s p o u s e d i e s . We s t i l l d o n ' t know much a b o u t how s o m e o n e r e s t r u c t u r e s t h e i r l i f e o v e r a l o n g p e r i o d o f t i m e . My s t u d y f o c u s e s o n t h e r e s t r u c t u r i n g o f l i f e a n d new s k i l l s t h a t a r e a c q u i r e d . T h e q u e s t i o n n a i r e t h a t I am a s k i n g y o u t o f i l l o u t i s t h e sa m e l e n g t h a s t h e q u e s t i o n n a i r e s y o u f i l l e d o u t i n t h e o r i g i n a l s t u d y ( 2 0 p a g e s ) . I am o n l y a s k i n g y o u t o f i l l o u t t h i s q u e s t i o n n a i r e o n c e . I t w i l l t a k e a b o u t a n h o u r t o c o m p l e t e . B e c a u s e I am t r y i n g t o g e t a s c o m p l e t e a s a m p l e a s p o s s i b l e , I w o u l d v e r y m u ch a p p r e c i a t e i t i f y o u w o u l d b e w i l l i n g t o p a r t i c i p a t e . T h i s i s a v e r y u n i q u e o p p o r t u n i t y t o s t u d y many f a c t o r s t h a t c a n n o t b e s t u d i e d i n a n y o t h e r w ay t h a n t o u s e t h e i n f o r m a t i o n y o u p r o v i d e d i n t h e o r i g i n a l s t u d y a n d t h e i n f o r m a t i o n y o u c a n p r o v i d e a t t h i s t i m e i n y o u r l i f e . As w i t h t h e o r i g i n a l s t u d y t h e i n f o r m a t i o n y o u p r o v i d e w i l l b e h e l d i n s t r i c t e s t c o n f i d e n c e a n d t h e r e w i l l b e n o d i r e c t a s s o c i a t i o n w i t h y o u . Y o u r r e s p o n s e s w i l l o n l y b e a t t a c h e d t o a n u m b e r . I f y o u h a v e a n y q u e s t i o n s , I h a v e s e t u p a t e l e p h o n e n u m b e r i n S a l t L a k e C i t y . I t i s 8 0 1 - 4 8 5 - 8 6 5 3 . You may l e a v e y o u r name a n d p h o n e n u m b e r a n d I w i l l r e t u r n y o u c a l l . O r i f y o u p r e f e r y o u may c o n t a c t me i n S o u t h e r n C a l i f o r n i a a t 8 1 8 - 5 8 4 - 9 7 3 3 . If you are willing to participate, please return the enclosed blue sheet in the stamped addressed envelope. I will then mail the questionnaire back to you. T h a n k y o u v e r y m uch f o r y o u r w i l l i n g n e s s t o p a r t i c i p a t e i n t h i s p r o j e c t . I a p p r e c i a t e i t v e r y m u c h . S i n c e r e l y , o W r i g h t MAy OTR U N IV E R SIT Y O F S O U T H E R N C A L IF O R N IA 15 40 A L C A Z A R S T R E E T . C H P 133. LO S A N G E L E S . C A L IF O R N IA 9UOJ3 102 TO: .I» Wright, MA. OTII. Ilesearcher llEIIEAVEMEA'T STl'UY IOLLOW-IP O/O (ierontology Onter l'niv«ni(y of Utah '2 .1 South Medical Driv« Salt Lake City, I T 114112 YES, I would bo willing to participate in your research. I understand that I will receive a 20 puge questionnaire in the mail with u stamped addressed envelope to use in returning it. I will only be asked to fill out this questionnaire once. It will take approximately one hour, I have made corrections to the mailing label below. Corrections: i N ’ n m e Address City, State. Zip. If I have any questions. I know that I can call and leave my name and number ut either 1101 Jll.ldlti.lll ISalt Lake City! or Itl8*<ili4*!)7ll<1 (California! and the researcher. Jo Wright, will return my call. November 28, 1994 u s e D e a r A few w e e k s a g o , I s e n t a l e t t e r t o y o u t h a t d e s c r i b e d a c u r r e n t r e s e a r c h p r o j e c t t h a t w a s u s i n g t h e p e o p l e t h a t h a d b e e n i n v o l v e d i n t h e 2 y e a r b e r e a v e m e n t s t u d y c o m p l e t e d by r e s e a r c h e r s a t t h e U n i v e r s i t y o f U t a h . I w a s a s k i n g t h a t t h i s sam e g r o u p a g a i n p a r t i c i p a t e i n f i l l i n g o u t a q u e s t i o n n a i r e ( o n e t i m e o n l y ) . I h a v e r e c e i v e d a w o n d e r f u l r e s p o n s e t o t h a t r e q u e s t . T h i s l e t t e r i s a f o l l o w u p l e t t e r r e q u e s t i n g t h a t y o u r e c o n s i d e r b e i n g a p a r t o f t h i s s t u d y . T h e s t r e n g t h o f t h e r e s u l t s w i l l come f r o m e v e r y o n e p a r t i c i p a t i n g i n t h i s r e s e a r c h a t t h i s t i m e . T he s u r v e y I am a s k i n g y o u t o f i l l o u t t a k e s a b o u t a n h o u r a n d i s s o m e w h a t s i m i l a r t o t h e o r i g i n a l s u r v e y s y o u f i l l e d o u t i n t h e f i r s t s t u d y . I know t h i s i s a v e r y b u s y t i m e o f y e a r a n d i f i t i s m o re c o n v e n i e n t y o u may t a k e u p u n t i l J a n u a r y 1 5 , 1 9 9 5 , t o c o m p l e t e t h e q u e s t i o n n a i r e . I f y o u c o u l d m a r k YES o n t h e e n c l o s e d s h e e t a n d m ake a n y name o r a d d r e s s c o r r e c t i o n s a n d s e n d t h e s h e e t b a c k t o d a y , I w o u l d v e r y much a p p r e c i a t e i t . I f y o u d o n o t w i s h t o p a r t i c i p a t e i n t h i s s t u d y , I w o u l d s t i l l v e r y much a p p r e c i a t e i t i f y o u w o u l d t a k e a m i n u t e t o m a r k t h e NO b o x a n d r e t u r n t h e f o r m s o t h a t I kn o w y o u a t l e a s t h a d a c h a n c e t o b e i n c l u d e d i n t h e s t u d y . A s t a m p e d a d d r e s s e d e n v e l o p e i s i n c l u d e d f o r y o u r c o n v e n i e n c e . I f i t i s m o r e c o n v e n i e n t y o u may c a l l a n d l e a v e a m e s s a g e a t 8 0 1 - 4 8 5 - 8 6 5 3 (SLC) i n d i c a t i n g y o u d o n o t w i s h t o p a r t i c i p a t e . J u s t l e a v e y o u r n am e a n d t h e n u m b e r a b o v e y o u r n am e. No f u r t h e r q u e s t i o n s w i l l b e a s k e d . T h a n k y o u f o r y o u r t i m e a n d a t t e n t i o n t o t h i s r e q u e s t . I h o p e y o u r h o l i d a y s e a s o n i s p l e a s a n t . I f y o u h a v e q u e s t i o n s , p l e a s e f e e l f r e e t o c a l l A nn, my r e s e a r c h a s s i s t a n t a t t h e a b o v e n u m b e r o r y o u may l e a v e y o u r n u m b e r a n d I w i l l c a l l y o u b a c k . S i n c e r e l y , J o W r i g h t , MA, OTR R e s e a r c h e r , D o c t o r a l C a n d i d a t e B e r e a v e m e n t S t u d y F o l l o w Up l MVKR.SITY hi SOI TIIFKN ( \ U I O R M \ U n AI.CAZAR STREET. H I T I - I.OS A S U E L E S . C A L I F O R M \ 'HHIIi TO: Jo Wright. AIA. OTIt. Researcher IIEItEAVBMEKT STl'HY lOLLOW-ll* c/o (icrontology ( «nt*r Univmitr of Utah 23 South Medical Drive Salt Lake City. IT H4II2 { j YES. I would be willing to participate in your research. 1 understand that I will receive a 20 page questionnaire in the mail with a stamped addressed envelope to use in returning it. I will only be asked to fill out this questionnaire once. It will take approximately one hour. I have made corrections to the mailing label out to the side. Corrections: I I \ti. I a m not interested in participating in this study at this time. II you liuve any questions, you can cull und leave your name and number at 1l0l-10.>-0(t.> J or speak with Ann (Research Assistant). Appendix B: University of Utah Study Instruments 105 College of Nursing Questionnaire Time ffl Thank you for agreeing to participate in this important study. There will be nearly 300 people in this project who have also recently experienced the death of their spouse. We realize that this is a difficult time for you so we encourage you to take your time as you answer the questions in this survey. We hope that you will be able to answer all of the questions so that we can learn the most about your experiences and feelings. When you finish please return the survey to us in the envelope that we have provided. We will be in touch with you again later. Thanks for your help. PLEASE BEGIN ON PAGE 2 Preliminary Information (Completed by Research Assistant) Sample 1 2 3 4 5 Respondent Number: __________ Session Number: (1) Research Assistant Name _______________________________ Date Questionnaire Delivered __________________________ (not coded) Date Questionnaire Returned_____________________________ Sampling Week _____ County: Salt Lake Davis Utah Weber 106 (2) QUESTIONNAIRE TIME 1 DEMOGRAPHIC INFORMATION I-. What is your sex? Male Female 2. What is your age? _________ ? 3. What was your spouse's age? 4. What is your race? White Oriental ____ Hispanic Black ____ Native American Other___ .5. Check the answer below which best describes your level of education. Did not graduate from high school High school graduate Attended some college or trade school College graduate Have done some additional graduate work 6. Are you currently employed? (Check one answer and then write in your occupation.) No (last occupation? ______________________________________ ) Part-time ... What do you do? Full-time ... What do you do? 7. How long were you married? 8. Have you ever been married before? No Yes (How many times? ______ (How many of these marriages ended with the death of your spouse? ) 9. What are your present living arrangements? Live alone Live with child or children Live with relative ... who? ____________________________ Live with friend Other ... describe 107 (3) 10. Do you have living children? No Yes (How many? ______ 11. How many of your children live within 50 miles of where you live? 12. Of all the people you know, is there one specific person that you can share your most personal thoughts and feelings with? Yes No (go to question # 13) If Yes, who is this person? ______________________________________ Is he/she readily available? _____ Yes No What kinds of things do you tell him/her? Does this person confide in you? Yes No 13. Do you feel that you have had an adequate opportunity to express your thoughts and feelings around others? Yes No 14. What are your present sources of financial support? (check all that apply) Savings ____ Social Security Retirement ____ Medicare/Medicaid Stocks/bonds ____ Welfare Family support Other (please specify) ________________ 15. How religious pf a person would you describe yourself to be? Not at all religious Slightly religious Moderately religious Quite religious Very religious 108 ( 4; 16. What is your religion? (membership or- preference) Catholic ____ Greek Orthodox Jewish ____ Mormon Protestant Other (specify denomination) __________________ None 17. How often do you attend church meetings or activities? Never Once or twice a year Several times a year About once a month Two or three times a month Once a week More than once a week 18. Do you believe in life after death? Yes Uncertain No 19. According to the scale below how happy would you say your marriage was? (Circle a number on the scale) 1..... 2....... 3..... 4..... 5-..... 6...... 7 Very Perfectly Unhappy Happy 20. Were you able to share your most personal thoughts and feelings with your spouse? Yes No 109 (5) The next several questions ask you to .write some answers that describe how you have felt and what you have done in the last few months since your spouse's deatn. Please write a brief answer to each question. 21. How did your spouse die? (Cause of death) 22. A. Was the death... expected unexpected 3. Was the death... ____ slow ____ sudden 23. Please briefly describe the circumstances of your spouse's death. (Include the following:) A. Were you present at the time of death? Yes No. B. Were others present? No Yes - Who?_________________ C. If your spouse's death was due to an illness, how long was he/she ill before he/she died? 1. Less than 2 months 2. 2-6 months 3. More than 6 months 4. Not applicable 24. Is there any single greatest problem that you have had related to your spouse's death? (Explain) 25. Have you gone to any professionals for help related to your grief? (Such as clergy, widow support groups, counselors, etc.) Yes ... Who? _______________________________________________ No 110 (6) Health Questions A. How would you describe your general health since the death of your spouse according to the scale below? (Circle a number from 1-7 that describes your health.) B. Have you gone to see a doctor for any reason since the death of your spouse? Yes. How many times? __________________________ No. C. Have you been hospitalized for any reason since your spouse's death? Yes. How many times? __________________________ No. D. Have you noticed a worsening in symptoms of chronic health problems since the death of your spouse? Yes. No. E. Do you take any prescription medications on a regular basis? Yes. How many? ________________________________ No. F. Since your spouse's death how many days were you so sick that you were unable to carry on your usual activities? ______ 1 — Poor Health 2 3 4 5 ■6...... 7 Excellent Health G. Do you have a regular exercise program? Yes. No. Ill (7) H. How many meals do you eat per day? _____________________________ I. Overall, how nutritious would you say that your daily diet is according to the scale below? (Circle a number.) 1..... 2...... 3...... 4..... 5......5...... 7 Poor Excellent J. Directions: Please check any of the following conditions your doctor has told you that you have at this time. 1. Heart condition 12. Liver disease 2. Circulation problems 13. Kidney disease 3. High blood pressure 14. Urinary problems 4. Anemia 15. Parkinson's disease 5. Diabetes 15. Stroke 6. Emphysema/bronch i t i s 17. Arthritis 7. Cataracts 18. Emotional problems 8. Stomach ulcers 19. Skin problems 9. Broken bones 20. Cancer 10. Gall bladder problems 21. Other (List) 11. Hernia Please review the list of health that you have experienced since problems below and check all of those the death of your spouse. 1. Loss of appetite 11. Hemorrhoids 2. Difficulty sleeping 12. Constipation 3. Difficulty swallowing 13. Bladder or urinary problems 4. Very tired 14. Joint pains 5. Headaches 15. Dizziness 6. Blurred vision 16. Skin rash or "shingles" 7. Difficulty breathing 17. Sweating 8. Pain in chest 18. Hair loss 9. Rapid heart beat 19. Muscle aches/pains 10. Abdominal pain 20. Problems concentrating 112 (8) Family, Friends and Relatives It is important for us to learn some things about your family and friends, we have a series of questions that we would like to ask you about these people so that we can better understand their importance and support to you. We would like you to make a list of these people first, and then have you answer a couple of questions about each person. Question: Of all the people that you know, including family, relatives, friends, and others, who are those that you feel closest to? These would be the people that are important and close to you. Write the names or initials of the 10 people that you are closest to in the blanks numbered from 1-10. You do not have to write 10, but the limit is 10. After you write these names, then answer tne questions that follow each name. 1. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 2. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this person? sister,etc.) (Friend, son, daughter, 3. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 4. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? vFriend, son, daughter, flame (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, flame (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, Name (or Initial) A. Is this person a male or female?__________________ B. What is your relationship to this person? (Friend, son, daughter, sister, etc.)______________________________________________ 114 (10) Family, Friends, & Relatives (continued) 26. If you feel that there are more than 10 people that you feel close to, about how many others are there?______ _____________________________ 27. Considering all of the people that you just mentioned, how easy is it for you to contact these people? (check one) Very difficult Fairly difficult Neither difficult nor easy Fairly easy Very easy 28. Considering these same people that you have mentioned, how many of them know each other? (check one) None of them A few of them Some of them Most of them A!1 of them 29. Considering these people as a qrouo: (check one box for each question below) Not Very Some- Quite Very Never Often_____ times____ Often Often A. How often do you contact them? B. How often do you confide in each other? | C. How often do you help each other? Not at Not Some- Quite Very all Very what close close D. How close do you feel to them? (check one box) 115 (n: 30. According to the scale below, how stressful has the death of your spouse been for you? (Circle a number of the scale.) 1----------------- 3__...4--------- 5........ -6---------- 7 Mot Stressful Very Stressful 31. How well do you feel that you have coped with this situation? (Circle a number on the scale.) Not at all Very Wei 1 32. According to this same kind of scale, how would you describe your feelings about yourself? (Circle.) 1..... 2...... 3......4......5...... 6...... 7 Very Negative Very Positive 33. How lonely have you been according to the scale below? (Circle one.) Not at All Lonely Very Lonely 116 (12) Checklist Questions Other researchers and counselors have indicated that we can better understand how people like yourself cope with their situation if we have people react to a series of specific questions. These questions may overlap with things that you have already said, but it is important that we not miss any of the information that will help us to help others in the future. We have several checklists for you to complete. They deal mostly with your feelings and your health. Although there are a number of questions, you can answer them rather quickly. It should take only a few minutes. Please take the time to answer each question. PRESENT FEELINGS Answer all of the following items by checking how you presently feel about your spouse's death. Check one box for each statement. Completely Mostly True & Mostly Completely True True False False False 1. I still cry when I think of my spouse. 2. I still get upset when I think about my spouse. 3. I cannot accept my spouse's death. 4. Sometimes I very much miss my spouse. 5. Even now it's painful to recall memories of my spouse. 117 (13) Completely Mostly True & Mostly Completely True True False False False 6. I am preoccupied with thougnts (often think) about my spouse. 7. I hide my tears when I think about my spouse. 8. No one will ever take the place in my life of my spouse. 9. I can't avoid thinking about my spouse. 10. I feel it's unfair that my spouse died. 11. Things and people around me still remind me of my spouse. 12. I am unable to accept the death of my spouse. 13. At times I still feel the need to cry for my spouse. 118 (K) Please choose the best answer for how you have felt over the past week. (For each statement below circle yes or no.) 1. Are you basically satisfied with yor life? yes / no 2. Have you dropped many of your activities and interests? yes / no 3. Do you feel that your life is empty? yes / no 4. Do you often get bored? yes / no 5. Are you hopeful about the future? yes / no 6. Are you bothered by thoughts you can't get out of your head? yes / no 7. Are you in good spirits most of the time? yes / no 3. Are you afraid that something bad is going to happen to you? yes / no 9. Do you feel happy most of the time? yes / no 10. Do you often feel helpless? yes / no 11. Do you often get restless and fidgety? yes / no 12. Do you prefer to stay at home, rather than going out and doing new things? yes / no 13. Do you frequently worry about the future? yes / no 14. Do you feel you have more problems with memory than most people? yes / no 15. Do you think it is wonderful to be alive now? yes / no 16. Do you often feel downhearted and blue? yes / no 17. Do you feel pretty worthless the way you are now? yes / no 13. Do you worry a lot about the past? yes / no 19. Do you find life very exciting? yes / no 20. Is it hard for you to get started on new projects? yes / no 21. Do you feel full of energy? yes / no 22. Do you feel that your situation is hopeless? yes / no 23. Do you think that most people are better off than you are? yes / no 24. Do you frequently get upset over little things? yes / no 119 (15) Please circle yes or no: 25. Do you frequently feel like crying? yes / no 26. Do you have trouble concentrating? yes / no 27. Do you enjoy getting up in the morning? yes / no 23. Do you prefer to avoid social gatherings? yes / no 29. Is it easy for you to make decisions? yes / no 30. Is your mind as clear as it used to be? yes / no 120 (16) Feelings About Myself For each of the following statements,- check the box which most closely approximates your own present feelings. Strongly Strongly Statement Agree Agree Disagree Disagree 1. I feel that I am a person of worth, at least on an equal plane with others. 2. I feel that I have a number of good qualities. 3. All in all, I am inclined to feel that I am a failure. 4. I am able to do things as well as most other people. 5. I feel I do not have much to be proud of. 6. I take a positive attitude toward myself. 7. On the whole, I am satisfied with myself. 8. I wish I could have more respect for myself. 9. 1 certainly feel useless at times. 10. At times I think I am no good at all. 121 (17) Abi1ities and Skills Now we would like to find out about some skills or abilities that you may or may not have. For each ability that is mentioned, please indicate to what extent you think you possess that ability: Not at all. Somewhat, or A lot. Not at A Statements: All Somewhat Lot 1. Ability to plan and cook meals that you know are nutritious for yourself and for your family 2. Ability to drive a car 3. Ability to do minor mechanical repairs 4. Ability to organize your time and use it effectively 5. Ability to be assertive -- to make requests of others and to say "no" when you need to without being overly aggressive 6. Ability to exercise self-control -- to direct or restrain your actions in order to achieve your goals 7. Ability to do math problems -- such as those necessary to balance your checkbook 3. Ability to cope with failures -- to experience setbacks or frustrations without losing confidence or hope 9. Ability to adapt -- to adjust readily to different or changing conditions 10. Ability to set goals objectively -- to decide what you want realistically, taking into account what you need, what the people around you need, and what you can and cannot do 11. Ability to manage finances — to budget wisely, to avoid financial difficulty by anticipating how you will handle expenses 12. Ability to identify resources - to find the people, friends, or agencies that can help meet your needs 13. Ability to organize and utilize the sources of help you have identified_ 14. Ability to understand your own leisure needs and to meet them 122 (18) Not at A Statements: All Somewhat Lot 15. Ability to appreciate, take part in, or act with a sense of humor 15. Ability to perform and endure the physical activities that are required of you during the day 17. Ability to plan things in advance 13. Ability to speak honestly and fluently about yourself -- to express your thoughts, feelings, and desires in a way that allows people to understand and know you 19. Ability to learn about and use public trans portation 20. Ability to keep your household organized and clean 21. Ability to learn about and use, when necessary, public facilities and services, such as the fire station, police station, hospital, etc. 22. Ability to concentrate — to focus and keep your attention on what you are doing 23. Ability to recognize interpersonal problems — to understand the nature and source of whatever difficulties you may have in your relations with others 24. Ability to understand quickly and adequately what people communicate to you — not only through their words, but also through their facial expressions, the way they stand, etc. 25. Ability to understand and anticipate how other people will react to your actions — the things you say or do 123 (19) Life Satisfaction This last checklist of items deals with your feelings about your life. After reading each statement, indicate whether you Agree or Disagree with it by checking the appropriate box. Question: 1. As I grow older, things seem better than I thought they would be. 2. I have gotten more of the breaks in life than most of the people I know. 3. This is the dreariest time of my life. 4. I am just as happy as when I was younger. 5. My life could be happier than it is now. 6. These are the best years of my life. 7. Most of the things I do are boring and monotonous. Agree Disagree 3. I expect some interesting and pleasant things to happen to me in the future. 9. The things I do are as interesting to me as they ever were. 10. I feel old and somewhat tired. 11. I feel my age, but it does not bother me. 12. As I look back on my life, I am fairly well satisfied. 124 (20) Question 13. I would not change my past life even if I could. 14. Compared to other people my age, I've made a lot of foolish decisions in my life. 15. Compared to other people my age, I make a good appearance. 16. I have made plans for things I'll be doing a month or year from now. 17. When I think back over my life, I didn't get most of the important things I wanted. 18. Compared to other people, I get down in the dumps too often. 19. I've gotten pretty much what I expected out of 1 ife. 20. In spite of what people say, the lot of the average person is getting worse, not better. Agree Disagree THANK YOU VERY MUCH FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE. PLEASE MAIL IT BACK TO US IN THE ENVELOPE THAT WE HAVE PROVIOED. 125 College of Nursing Questionnaire Time #4 This is the last questionnaire in our study. We have appreciated your time and effort during the past two years and wish you the best in the future. We have learned a great deal from you and the other 300 people in our study. We hope that we will be in a better position to help other people in the future because of what we have learned. If your schedule permits, please finish answering the questions within three days and return the survey to us in the envelope that we have provided. Once again, thanks for your help. PLEASE BEGIN ON PAGE 2 Preliminary Information (Completed by Research Assistant) Sample 1 2 3 4 5 Respondent Number: __________ Session Number: (4) Research Assistant Name ________________________________ Date Questionnaire Delivered ___________________________(not coded) Date Questionnaire Returned_____________________________ Sampling Week _____ County: Salt Lake Davis Utah Weber Group ID 126 QUESTIONNAIRE TIME -4- I. Are you currently employed? (Check one answer and then write in your occupation.) No (last occupation? ____________________________________ Part-time ... What do you do? Full-time ... What do you do? 2. What are your present living arrangements? Live alone Live with child or children Live with relative ... who? ______ Live with friend Live with new spouse only. Live with new spouse and children. Other ... describe 3. Of all the people you know, is there one specific person that you can share your most personal thoughts and feelings with? Yes No (go to question #4) If Yes, who is this person? _______________________________________ Is he/she readily available? _____ Yes No What kinds of things do you tell him/her? Does this person confide in you? ____ Yes No 4. Do you feel that you have had an adequate opportunity to express your thoughts and feelings around others? Yes No 127 5. How religious of a person would you describe yourself to be? Not at all religious Slightly religious Moderately religious quite religious Very religious 6. How often do you attend church meetings or activities? Never Once or twice a year Several times a year About once a month Two or three times a month Once a week More than once a week 7. Do you believe in life after death? Yes ___ Uncertain No 8. What are your present sources of financial support? (check al 1 that apply) Savings ____ Social Security Retirement ____ Medicare/Medicaid Stocks/bonds ____ Welfare Family support Other (please specify) _________________ 9. How would you describe the adequacy of your current financial situation according to the choices below? I have problems making ends meet. My financial situation is comfortable. My income is more than adequate to meet my needs. 10. According to the scale below how happy would you say your marriage was? (Circle a number on the scale) 1- Very Perfectly Unhappy Happy 128 (4) 11. Is there any single greatest problem that you have had related to your spouse's death? (Explain) 12. Have you gone to any professionals for help related to your grief? (Such as clergy, widow support groups, counselors, etc.) Yes ... Who? ________________________________________________ No 13. Have you done better or worse than you expected? Worse than expected Better than expected Don't know 14. (A) Since your spouse died when did you experience the most difficulty? (B) Why was this the most difficult time? 129 (5) Health Questions A. How would you describe your general health in the past three months according to the scale below? (Circle a number from 1-7 that describes your health.) Poor Excellent Health Health B. Have you gone to see a doctor for any reason in the past three months? Yes. How many times? __________________________ No. C. Have you been hospitalized for any reason in the past three months? Yes. How many times? __________________________ No. D. Have you noticed a worsening in symptoms of chronic health problems in the past three months? Yes. No. E. Do you take any prescription medications on a regular basis? Yes. How many? ________________________________ No. F. In the past three months how many days were you so sick that you were unable to carry on your usual activities? _______________________ G. Do you have a regular exercise program? Yes. No. H. How many meals do you eat per day? 130 (6) I. Overall, how nutritious would you say that your daily diet is according to the scale below? (Circle a number.) 1..... 2...... 3...... 4...... 5......6...... 7 Poor Excellent J. Directions: Please check any of the following conditions your doctor has told you that you have at this time. 1. Heart condition 12. Liver disease 2. Circulation problems 13. Kidney disease 3. High blood pressure 14. Urinary problems 4. Anemia 15. Parkinson's disease 5. Diabetes 16. Stroke 6. Emphysema/bronchi ti s 17. Arthritis 7. Cataracts 18. Emotional problems 8. Stomach ulcers 19. Skin problems 9. Broken bones 20. Cancer 10. Gall bladder problems 21. Other (List) 11. Hernia K. Please review the list of health problems below and check all of those that you have experienced in the past three months. 1. Loss of appetite 11. Hemorrhoids 2. Difficulty sleeping 12. Constipation 3. Difficulty swallowing 13. Bladder or urinary problems 4. Very tired 14. Joint pains 5. Headaches 15. Dizziness 6. Blurred vision 16. Skin rash or "shingles" 7. Difficulty breathing 17. Sweating 8. Pain in chest 18. Hair loss 9. Rapid heart beat 19. Muscle aches/pains 10. Abdominal pain 20. Problems concentrating 1 3 1 (7) Family^ Friends and Relatives Similar to the last time, we would like to learn some things about your family and friends. We have a series of questions that we would like to ask you about these people so that we can better understand their importance and support to you. Again, we would like you to make a list of these people first, and then have you answer a couple of questions about each person. Question: Of all the people that you know, including family, relatives, friends, and others, who are those that you feel closest to? These would be the people that are important and close to you. Write the names or initials of the 10 people that you are closest to in the blanks numbered from 1-10. You do not have to write 10, but the limit is 10. After you write these names, then answer the questions that follow each name. 1. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this person? sister, etc.) (Friend, son, daughter, 2. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister,etc.) person? (Friend, son, daughter, 3. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister,etc.) person? (Friend, son, daughter, 4. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 132 5. Name (or Initial) A. Is this person a male or female? D u • What is your relationship to this sister, etc.) person? (Friend, son, daughter, 6. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 7. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 8. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 9. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 10. Name (or Initial) A. Is this person a male or female? B. What is your relationship to this sister, etc.) person? (Friend, son, daughter, 1 3 3 (9) Family, Friends, & Relatives (continued) 12. If you feel that there are more than 10 people that you feel close to, about how many others are there? __________ 13. Considering all of the people that you just mentioned, how easy is it for you to contact these people? (check one) Very difficult Fairly difficult Neither difficult nor easy Fairly easy Very easy 14. Considering these same people that you have mentioned, how many of them know each other? (check one) None of them A few of them Some of them Most of them All of them 15. Considering these people as a group: (check one box for each question below) Not Very Some- Quite Very Never Often times Often Often A. How often do you contact 1 them? B. How often do you confide I in each other? j C. How often do you help I each other? I Not at Not Some- Quite Very all Very what close close i i ; i- - - - - - - 1- - - - D. How close do you feel to j j j them? (check one box) I I I 134 (10) 16. According to the scale below, how stressful has the death of your spouse beer, for you? (Circle a number on the scale.) 1...... 2..... 3.......4...... 5..... 6...... 7 Not Stressful Very Stressful 17. How well do you feel that you have coped with this situation? (Circle a number on the scale.) 1...... 2..... 3....... 4...... 5..... 6...... 7 Not at all Very Well 18. How satisfied are you with how well you have coped with this situation? (Circle.) 1...... 2..... 3....... 4...... 5..... 6...... 7 Not at Very Satisfied All Satisfied 19. According to this same kind of scale, how would you describe your feelings about yourself? (Circle.) 1...... 2..... 3....... 4...... 5..... 6...... 7 Very Negative Very Positive 20. How lonely have you been according to the scale below? (Circle one.) 1...... 2..... 3....... 4...... 5..... 6...... 7 Not at All Very Lonely Lonely 135 (11) Checklist Questions Just as we did in earlier questionnaires, we would like you to respond to a series of statements that deal with your feelings, health, and everyday behaviors. We want to ask the same questions we did a few months ago because we want to know if any of these things have changed. We have several checklists for you to complete. Although there are a number of questions, you can answer them rather quickly. It should take only a few minutes. Please take the time to answer each question according to your present feelings and situation. PRESENT FEELINGS Answer all of the following items by checking how you presently feel about your spouse's death. Check one box for each statement. Completely Mostly True & Mostly Completely True True False False False 1. I still cry when I think of my spouse. 2. I still get upset when I think about my spouse. 3. I cannot accept my spouse's death. 4. Sometimes I very much miss my spouse. 5. Even now it's painful to recall memories of my spouse. 136 (12) Completely Mostly True & Mostly Completely True True False False False 6. I am preoccupied with thoughts (often think) about my spouse. 7. I hide my tears when I think about my spouse. 8. No one will ever take the place in my life of my spouse. 9. I can't avoid thinking about my spouse. 10. I feel it's unfair that my spouse died. 11. Things and people around me still remind me of my spouse. 12. I am unable to accept the death of my spouse. 13. At times I still feel the need to cry for my spouse. 137 (13) Please choose the best answer for how you have felt over the past week. For each statement below circle yes or no. In case you are uncertain please force yourself to select either yes or no. 1. Are you basically satisfied with your life? yes no 2. Have you dropped many of your activities and interests? yes no 3. Do you feel that your life is empty? yes no 4. Do you often get bored? yes no 5. Are you hopeful about the future? yes no 6. Are you bothered by thoughts you can't get out of your head? yes no 7. Are you in good spirits most of the time? yes no 8. Are you afraid that something bad is going to happen to you? yes no 9. Do you feel happy most of the time? yes no 10. Do you often feel helpless? yes no 11. Do you often get restless and fidgety? yes no 12. Do you prefer to stay at home, rather than going out and doi ng new things? yes no 13. Do you frequently worry about the future? yes no 14. Do you feel you have more problems with memory than most people? yes no 15. Do you think it is wonderful to be alive now? yes no 16. Do you often feel downhearted and blue? yes no 17. Do you feel pretty worthless the way you are now? yes no 18. Do you worry a lot about the past? yes no 19. Do you find life very exciting? yes no 20. Is it hard for you to get started on new projects? yes no 21. Do you feel full of energy? yes no 22. Do you feel that your situation is hopeless? yes no 23. Do you think that most people are better off than you are 7 yes no 24. Do you frequently get upset over little things? yes no 138 (14) Please circle yes or no: 25. Do you frequently feel like crying? yes / no 26. Do you have trouble concentrating? yes / no 27. Do you enjoy getting up in the morning? yes / no GO CO Do you prefer to avoid social gatherings? yes / no 29. Is it easy for you to make decisions? yes / no CO o Is your mind as clear as it used to be? yes / no 139 (15) Feelings About Myself For each of the following statements, check the box which most closely approximates your own present feelings. Strongly Strongly Statement Agree Agree Disagree Disagree V. I feel that I am a person of worth, at least on an equal plane with others. 2. I feel that I have a number of good qualities. •3. All in all, I am inclined to feel that I am a failure. A. I am able to do things as well as most other people. 5". I feel I do not have much to be proud of. 6-. I take a positive attitude toward myself. 7. On the whole, I am satisfied with myself. 8. I wish I could have more respect for myself. 9. I certainly feel useless at times. 10. At times I think 1 am no good at all. 140 (16) Abilities and Skills Now we would like to find out about some skills or abilities that you may or may not have. For each ability that is mentioned, please indicate to what extent you think you possess that ability: Not at all, Somewhat, or A lot. Not at A Statements: All Somewhat Lot 1. Ability to plan and cook meals that you know are nutritious for yourself and for your family 2. Ability to drive a car 3. Ability to do minor mechanical repairs 4. Ability to organize your time and use it effecti vely 5. Ability to be assertive -- to make requests of others and to say "no" when you need to without being overly aggressive 6. Ability to exercise self-control -- to direct or restrain your actions in order to achieve your goals 7. Ability to do math problems -- such as those necessary to balance your checkbook 8. Ability to cope with failures -- to experience setbacks or frustrations without losing confidence or hope 9. Ability to adapt -- to adjust readily to different or changing conditions 10. Ability to set goals objectively -- to decide what you want realistically, taking into account what you need, what the people around you need, and what you can and cannot do 11. Ability to manage finances -- to budget wisely, to avoid financial difficulty by anticipating how you will handle expenses 12. Ability to identify resources - to find the people, friends, or agencies that can help meet your needs 13. Ability to organize and utilize the sources of help you have identified 14. Ability to understand your own leisure needs and to meet them 141 Statements: 15. Ability to appreciate, take part in, or act with a sense of humor 16. Ability to perform and endure the physical activities that are required of you during the day 17. Ability to plan things in advance 18. Ability to speak honestly and fluently about yourself -- to express your thoughts, feelings, and desires in a way that allows people to understand and know you 19. Ability to learn about and use public trans portation 20. Ability to keep your household organized and clean 21. Ability to learn about and use, when necessary, public facilities and services, such as the fire station, police station, hospital, etc. 22. Ability to concentrate -- to focus and keep your attention on what you are doing 23. Ability to recognize interpersonal problems -- to understand the nature and source of whatever difficulties you may have in your relations with others 24. Ability to understand quickly and adequately what people communicate to you -- not only through their words, but also through their facial expressions, the way they stand, etc. 25. Ability to understand and anticipate how other people will react to your actions -- the things you say or do (17) Not at A All Somewhat Lot 142 (18) Life Satisfaction This last checklist of items deals with your feelings about your life. After reading each statement, indicate whether you Agree or Disagree with it by checking the appropriate box. Question: Agree Disagree 1. As I grow older, things seem better than I thought they would be. 2. I have gotten more of the breaks in life than most of the people I know. 3. This is the dreariest time of my life. 4. I am just as happy as when I was younger. 5. My life could be happier than it is now. 6. These are the best years of my life. 7. Most of the things I do are boring and monotonous. 8. I expect some interesting and pleasant things to happen to me in the future. 9. The things I do are as interesting to me as they ever were. 10. I feel old and somewhat tired. r 11. I feel my age, but it does not bother me. 12. As I look back on my life, I am fairly well satisfied. Question Agree Disagree 13. I would not chage my past life even if I could. 14. Compared to other people my age, I've made a lot of foolish decisions in my life. 15. Compared to other people my age, I make a good appearance. 16. I have made plans for things I'll be doing a month or year from now. 17. When I think back over my life, I didn't get most of the important things I wanted 18. Compared to other people, I get down in the dumps too often. 19. I've gotten pretty much what I expected out of 1 i f e . 20. In spite of what people say, the lot of the average person is getting worse, not better. PLEASE TURN TO NEXT PAGE 144 (20) Support Group Information Although it has been quite some time since you last attended the support group meetings we conducted, we would like to ask some questions concerning how you may feel now about the groups, given that some time has passed. 1. What did you like most about your group sessions? 2. Is there anything you disliked about the sessions? 3. According to the scale below, how helpful were these meetings for you? (Circle a number) 1.....2..... 3..... 4..... 5 Not at all Extremely helpful helpful 4. How could the group sessions have been more helpful? 5. What was the main need that you hoped would be filled by participating in these groups? (Please choose only the main one.) _______ Emotional support _______ Obtain information about doing certain tasks _______ Meet new people _______ A desire to help others _______ Other - Please specify._________________________________________ 145 (21) 6. How well was this need filled by participating in the group sessions according to the scale below? 1.... 2..... 3-.... 4..... 5 Not At Very Well All 7. If your need was not filled adequately, how, if at all, did you fulfill it? Do you feel that: (check one) ______ The eight weekly meetings were sufficient? ______ Ten monthly meetings might have been useful in addition to the weekly ones? ______ Some other arrangement would be better. (Please specify:_________________________________________ 9. Have you become friends with anyone in your group, or contacted anyone in your group outside of the group meetings? ______ No (Go to #10) ______ Yes (Answer A thru D below) A. If yes, how often have you had contact with them outside of group meetings? Not very often Sometimes Quite often Very often B. How close do you feel to them? Not at all Not very close _Somewhat close _Quite close _Very close 146 (22) C. What do you normally do when you get together with any of them? D. What do you usually talk about? 10. Do you have any other comments about the groups? 147 (23) Comments About This Study Since this is the final questionnaire, we would like very much to find out what you have thought about this study. Please answer these questions according to how you feel and do not hesitate to make criticisms._____ _______________________________ We know that sometimes people's expectations at the beginning of the project might change during the course of the project. How willing or excited were you in the beginning to participate in this project on a scale of 1 to 5? 1 2 3 4 5 Not at all Very Willing Willing How glad are you that you have participated in this project on a scale of 1 to 5? 1 2 3 4 5 Not at all Very Glad Glad Please explain: _____________________________________________________ Were the questionnaires too long? Yes No How much time did it take you to complete each questionnaire? hour(s) Did you have any specific problems with the questionnaires? (Please explain) 148 (24) 6. How extensive were the inconveniences that you may have experienced while in this project on a scale of 1 to 5? 1 2 3 4 5 Minimal Major Inconvenience Inconvenience Please explain:___ ___________________________________________________ 7. In your opinion, how could we have improved our study? 8. Did you benefit in any way from being in our study? (How?) 9. If additional funding was made available to us in the future, would you be willing to: (check al1 that apply) ______ Fill out additional questionnaires as a follow-up to this study. ______ Be interviewed indepth by a trained interviewer. ______ Lead a support group for others who have lost their spouse. THANKS AGAIN FOR ALL OF YOUR HELP. YOU HAVE BEEN VERY KIND TO HELP US SO MUCH. 149 Appendix C: Comparison Between Items From The Three Questionnaires Used In This Study The following table compares the questions or instruments used in the original University of Utah study with the questions and instruments used in this study's questionnaire. Many of these questions will be analyzed for changes from the original study by the University of Utah (U of U): Time 1, questionnaire administered a short time following the death of the spouse or the final questionnaire, Time 2, administered approximately two years after the death of the spouse and the responses given on the questionnaire designed for this proposed study, Time 3, eight years following the death of the spouse. The abbreviates for this scale are L = Likert Scale and I = Instrument. TIME 1— (U of U) Near time of death of spouse. TIME 2— (U of U ) 2 years since death of spouse. Time 3— 8 years since death of spouse. Respondent number SAME SAME 1. sex 2. age 1.SAME 3.spouse's age 4 .race 5.educational level 6.currently employed 1.SAME 7.length of marriage 150 TIME 1— (U of U) Near time of death of spouse. TIME 2--(U of U ) 2 years since death of spouse. Time 3— 8 years since death of spouse. 8.have you been married before? 9.current living arrangement 2.SAME 2.SAME 10.living children 3.SAME 11.children within 50 miles 4.SAME 12.person to confide in 3.SAME 13.adequate opportunity to express thoughts 4.SAME 14.sources of fiscal support 8.SAME 9.adequacy of fiscal support 5.SAME 15.how religious person is 5.SAME 16.religion 17.freq. attend church activities 6.SAME 18.belief in life after death 7.SAME 19.how happy was your marriage (L) 10.SAME 20.able to share personal thoughts with spouse 21.cause of death 22.expected/unexpect ed, slow/sudden 23.circumstances of death 151 TIME 1— (U of U) Near time of death of spouse. TIME 2— (U of U ) 2 years since death of spouse. Time 3— 8 years since death of spouse. 24.single greatest problem related to spouse's death 11.SAME 25.professional contact for grief 12.SAME 6.SAME 13.dealt w/grief: better/worse 8.SAME 14.most difficult time since, when & why 11 & 12.SAME A.general health (L) A.SAME 9.SAME B.seen MD since death B.SAME C.hospitalized since death C.SAME D.worsening of chronic health problem D.SAME E.prescription meds E.SAME F.sick days since death of spouse F.SAME G.regular exercise program G.SAME H.#meals per day H.SAME I.nutrition of daily diet (L) I.SAME J.medical conditions at this time (list of 21) J.SAME K.health problems since death of spouse(list of 20) K.SAME 7.support system consistent, decrease,increase 152 TIME 1— (U of U) Near time of death of spouse. TIME 2— (U of U ) 2 years since death of spouse. Time 3— 8 years since death of spouse. 1-10,26. Family, friends, relatives feel close to. (up to 10) 1-10,12.SAME 27.ease of contact friend, family, relatives 13.SAME 28.interrelationship of friends, family, relatives 14.SAME 29.grouped contact and feelings of closeness 15.SAME 30.stress of death (L) 16.SAME 31.how well coped? (L) 17.SAME 13.SAME 18.how satisfied with how coped 14.SAME 32. feelings about self (L) 19.SAME 15.SAME 33. how lonely? (L) 20.SAME 10.SAME Present Feelings about death of spouse (I) 13 SAME Yesavage Depression Scale 30 items (I) SAME SAME Rosenberg Self esteem (I) 10 item SAME SAME Abilities & Skills 25 item (I) SAME SAME Neugarten Life Satisfaction 20 item (I) SAME SAME activities before death of spouse 153 TIME 1— (U of U) Near time of death of spouse. TIME 2— (U of U ) 2 years since death of spouse. Time 3— 8 years since death of spouse. activities since death of spouse 3 most important skills questions about study willingness to be interviewed 154 Appendix D: Research Committee Consent Proposal ,*949003 REVIEW CATEGORY: C RESEARCH COMMITTEE PROFESSIONAL STAFF ASSOCIATION £ AND RESEARCH COMMITTEE UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE Date: 09/06/94 To: JoAnne Wright, M.A. Clinical Instructor Dept of Occupational Therapy Clinical Sciences Annex, #133 HEALTH SCIENCES CAMPUS (213)342-2850 FROM: RESEARCH COMMITTEE Darcy V. Spicer, M.D. Trailer #25, Unit I 1200 N. State Street Los Angeles, CA 90033 (213) 223-2340/2349 TITLE OF PROPOSAL: OLDER ADULT OCCUPATIONAL RESTUCTURING AFTER THE DEATH OF A SPOUSE Action Date: 09/06/94 Action Taken: Approved Committee : RESEARCH COMMITTEE SECRETARY Note: The protocol and informed consent were reviewed and APPROVED by Dr. Darcy Spicer, Secretary of the Research Committee, on August 30, 1994. A new application assigned Review Category C. (Research Committee Office #949-003) If any adverse event occurs during the study, it must be reported immediately to the Research Committee, the sponsor and the FDA. Approval of this study expires August/1995. Review Category C - Requires annual reporting by review form. 155 Date: 09/06/94 To: JoAnne Wright, M.A. Clinical Instructor Dept of Occupational Therapy Clinical Sciences Annex, #133 HEALTH SCIENCES CAMPUS (213)342-2850 From: RESEARCH COMMITTEE Darcy v. Spicer, M.D. Trailer #25, Unit I 1200 N. State street Los Angeles, CA 90033 (213) 223-2340/2349 Subject: Procedure for handling of proposal pertaining to human studies TITLE OF PROPOSAL: OLDER ADULT OCCUPATIONAL RESTUCTURING AFTER THE DEATH OF A SPOUSE The number 949003 has been assigned to the proposal mentioned above. This RESEARCH COMMITTEE OFFICE HUMBER MUST be used for all future in quiries, correspondence, renewals and continuations pertaining to this particular study. Thank you. Appendix E: Questionnaire For This Study 156 Thank you for your willingness to participate in this important study. Some of the questions are similar to questions you were asked when you originally participated in the bereavement study. Please answer these questions as they apply to yoL now unless it states otherwise. If you have any problem answering a question, just answer it the best you can. There are no right or wrong answers tc any of these questions. If your schedule permits, please finish answering the questions within three days and return the survey in the envelope that has been provided. This questionnaire will take about 45 minutes to complete. It does not need to be finished in one sitting. It may seem that there are a lot of questions but filling out the questionnaire goes quite quickly. Please be assured all responses will be kept confidential. If you have any questions you would like to ask, you may call 801 485-8653, leave your name and number and I will get back to you as soon as I can to answer your questions. THANK YOU VERY MUCH FOR YOUR HELP. Respondent # 157 1. What is your age'.' ______________ 2 . W hat are your current living arrangem ents ' Live alone Live with child or children Live with relative W ho1 .'________________ Live with a triend Remarried W hat year ' _____________ Other Describe_________________ 3. Do you have living children? No Yes (How many?______________ ) 4 How many o f your children live w ithin 50 m iles o f w here you live?_____ 5. How would you describe the adequacy of your current financial situation? 1 have a problem m aking ends meet. My financial situation is com fortable My income is m ore than adequate to m eet my needs. 6 . Have you gone to any professionals for help related to your grief.' (Such as clergy, widow support groups, counselors, etc) Please list A L L types o f professionals No Yes W ho?_____________________________________________________________________ For how long?___________________________________________________________ 7. Since the death of your spouse, do you feel your support system (close friends and family) has: Stayed consistent Decreased Increased 8 . Have you dealt with the grief associated w ith losing your spouse better or w orse than vou expected? W orse than expected Better than expected Not Sure 9. How would you describe your general health since the death of your spouse? (Circle a number on the scale.) -7 Poor Excellent 10. Since the death of your spouse, how lonely in general have you been according to the scale below? (Circle a number on the scale.) Not at All Very Lonely Lonely 11. When did you expenence the most difficulty dealing with the loss of your spouse? 12. Why was this the most difficult time? 13. According to the scale below, in general how well do you feel you have cooed with living without your spouse? (Circle a number on the scale.) 1- Not at all well Very well 14. How satisfied are you with how you have coped with living without your spouse? (Circle a number on the scale.) Not at Very satisfied All satisfied 15. According to this same kind of scale, how would you descnbe your current feelings about yourself? (Circle a number on the scale.) 1-------------- 2---------------3--------------4 ----------------5---------6- Very Negative 7 Very Positive Checklist Questions O ther researchers anil counselors have indicated that we can better understand how people like you cope with their situation it' we have people react to a series o f specific questions. These questions may overlap w ith things that you have already said, but it is im portant that we not miss any o f the inform ation that will help us to help others in the future. We have several checklists for you to com plete. They deal mostly w ith your feelings and your health. Although there are a num ber o f questions, you can answ er them rather quickly. It should take only a few minutes Please choose the best answ er for how you have felt over the nast w eek. (For each statement below circle yes or n o .) 1. Are you basically satisfied with your life? YES NO s Have you dropped many of your activities and interests? YES NO 3. Do you feel that your life is em pty? YES NO 4. Do you often get bored? YES NO 5. Are you hopeful about the future? YES NO 6 . Are you bothered by thoughts you ca n ’t get out o f your head? YES NO 7. Are you in good spirits m ost o f the time? YES NO 8 . Are you afraid that som ething bad is going to happen to you? YES NO 9. Do you feel happy m ost o f the time? YES NO 10. Do you often feel helpless? YES NO 11. D o you often get resdess and fidgety? YES NO 12. Do you prefer to stay at hom e, rather than going out and doing new things? YES NO 13. Do you frequently worry about the future? YES NO 14. Do you feel you have m ore problem s with mem ory than m ost people? YES NO 15. Do you think it is wonderful to be alive now? YES NO 160 16. Do you often feel dow nhearted and blue? YES NO 17. Do you feel pretty w orthless the way you are now? YES NO 18. Do you w orry a lot about the past? YES NO 19. Do you find life very exciting? YES NO 20. Is it hard for you to get started on new projects? YES NO 21, Do you feel full o f energy? YES NO 22. Do you feel that your situation is hopeless? YES NO 23. Do you think that most people are better o ff than you are? YES NO 24. Do you frequently get upset over little things? YES NO 25. Do you frequently feel like crying? YES NO 26. Do you have trouble concentrating? YES NO 27. Do you enjoy getting up in the m orning? YES NO 28. Do you prefer to avoid social gatherings? YES NO 29. Is it easy for you to make decisions? YES NO 30. Is your mind as clear as it used to be? YES NO 161 For each of the following statements, check the box which most closely approximates your own present feelings. Strongly Agree. Agree. Disagree or Strongly Disagree. Strongly Agree Agree Disagree I Strongly Disagree 1. I feel that I am a person of worth, at least on an equal plane with others. 2. I feel that I have a number of good qualities. i 3. All in all, I am inclined to feel that I am a failure. i 4. I am able to do things as well as m ost other people. 5. I feel I do not have much to be proud of. 6. I take a positive attitude toward myself. 7. On the whole, I am satisfied with myself. 8. I wish I could have m ore respect for myself. 9. I certainly feel u se le ss at times. 10. At tim es I think I am no good at all. 162 On the next few pages are activities that you might have engaged in BEFORE THE DEATH OF YOUR SPOUSE. Please place a check in the box that best represents who was most responsible for each activity when your spouse was alive The choices are: SPOUSE—Your Spouse mainly took care of it. YOU You mainly took care of it. SHARED—Both of you equally took care of it OTHER— Someone other than you or your spouse took care of it. N/A Activity not part of your routines. (As you fill out the form, please feel free to refer back to this list as often as necessary) |SPOUSE YOU SHARED | OTHER j N/A HOUSEHOLD ACTIVITIES | 1 i 1 General cooking | Cleaning | Laundry 1 Ironing | Using and maintaining mapr household appliances/machines Mending clothes 1 i I HOME REPAIRS | | Doing minor plumbing | | Doing minor electncal repairs General use of tools (wrencns, pliers, etc) Wintenzing the home Doing minor repairs on appliances Doing minor repairs on furniture Locating where to turn electricity, water and gas on and off FINANCIAL MATTERS Allocating financial resources Organizing and maintaining files Balancing a checkbook (monthly) Paying bills Filing insurance, Medicare, Medicaid, Social Security claims, & tax forms LEGAL Setting up or closing a will or an estate 164 SPOUSE YOU SHARED OTHER N/A i Transferring car and house titles Selecting a lawyer Setting up a living will General legal issues YARDWORK Doing general lawn care & gardening General maintenance of outside Cleanng snow from sidewalks and driveways CONSUMER ISSUES Grocery shopping Using products to become more functionally independent (i.e. garbage cans with wheels, microwave ovens) NUTRITION AND HEALTH Maintaining an exercise schedule Maintaining general nutrition and proDer diet Medications TRANSPORTATION Filling the gas tank Changing the oil/checking tire pressure Knowing when and where to service car Identify resources in the community related to Transportation COMMUNITY RESOURCES Identify resources in the community related to: SPOUSE YOU SHARED OTHER N/A I Educational programs (i.e. community schools, university and college courses) Senior centers RECREATION AND LEISURE Planning vacations Finding groups with common social interests Learning a new hobby Planning social activities | Keeping in touch with family and friends. The next few pages list the same activities that you just answered questions about. Please go through the following list (starting on the next page) and look at each activity and how you have accomplished it SINCE THE DEATH OF YOUR SPOUSE. Place a check in the box that BEST represents how you’ve handled each situation. Your choices are: KNEW HOW you already knew how to accomplish this task LEARNED HOW— you learned how to accomplish this task SOMEONE ELSE--someone else performs this task for you N/A---------------------activity not part of your routines. (As you fill out the form, please feel free to refer back to this list as often as necessary) KNEW HOW LEARNED HOW SOMEONE ELSE N/A HOUSEHOLD ACTIVITIES General cooking/ cooking for one Cleaning Laundry Ironing Using and maintaining maior household appliances/machines Mending clothes HOME REPAIRS Doing minor plumbing Doing minor electncal repairs General use of tools (wrenchs. pliers, etc) Wintenzing the home Doing minor repairs on appliances Doing minor repairs on furniture Locating where to turn electricity, water and gas on and off FINANCIAL MATTERS Allocating financial resources Organizing and maintaining files Balancing a checkbook (monthly) Paying bills Filing insurance, Medicare, Medicaid, Social Security claims. & tax forms. LEGAL Setting up or closing a will or an estate 168 KNEW HOW LEARNED HOW SOMEONE ELSE N/A Transferring car and house titles Selecting a lawyer Setting up a living will General legal issues YARDWORK Doing general lawn care & gardening General maintenance of outside Cleanng snow from sidewalks and driveways CONSUMER ISSUES Grocery shopping Using products to become more functionally independent (i.e. garbage cans with wheels, microwave ovens) NUTRITION AND HEALTH Maintaining an exercise schedule Maintaining general nutrition and proper diet Medications TRANSPORTATION Filling the gas tank Changing the oil/checking tire pressure Knowing when and where to service car Identify resources in the community related to Transportation 169 KNEW HOW LEARNED HOW SOMEONE ELSE N/A COMMUNITY RESOURCES Identify resources in the community related to: Educational programs (i.e. community schools, university and college courses) Senior centers RECREATION AND LEISURE Planning vacations Finding groups with common social interests Learning a new hobby Planning social activities Keeping in touch with family and friends. 170 1. The seco n d Important Skill or Activity I had to learn: 2. How did you m ostly learn this skill? (CHECK ONE RESPONSE ONLY) a. trial and error by m yself b. learned or h elp ed by a friend c. learned or h elp ed by a relative d. learned or h elped by paying so m eo n e e. other (describe)________________________________________ 3 . Do you feel that learning to do this new thing effected you in any of the following w ays? (CHECK ALL THAT APPLY) a. feel better about m yself b. be m ore independent c. keep busy d. deal better with th e lo ss of my sp o u se e. get along better with others f. anything else? (describe)_______________________________ 4. Do you feel that not being able to do this task m ade it m ore difficult for you to cop e with your sp o u se 's death? (CHECK ONE ONLY) a. Yes, a lot m ore difficult b. Yes, som ew hat m ore difficult c. Yes, but only a little bit more difficult d. No, it h asn ’ t m ade it m ore difficult 171 During the period of time you have b een without a sp o u se in the past 1 0 + years, what w ore the THREE m ost important skills or activities you have had to learn? lease list ea c h o n e (ONE PER PAGE) and answ er the questions below related to each ne. , One new Skill or Activity I had to learn: . How did you m ostly learn this skill? (CHECK ONE RESPONSE ONLY) a. trial and error by m yself b. learned or helped by a friend c. learned or helped by a relative d. learned or helped by paying so m eo n e e. other (describe)________________________________________ Do you feel that learning to do this n ew thing effected you in any of the following ways? (CHECK ALL THAT APPLY) a. feel better about m yself b. be m ore independent c. keep busy d. deal better with the lo ss of my sp o u se e. get along better with others f . anything else? (describe)_______________________________ Do you feel that not being able to d o this task m ade it more difficult for you to cop e with your sp o u s e ’s death? (CHECK ONE ONLY) a. Yes, a lot m ore difficult b. Yes, som ew hat m ore difficult c. Yes, but only a little bit m ore difficult d. No, it h asn ’ t m ade it more difficult 172 1. A third new Skill or Activity I had to learn: 2. How did you m ostly learn this skill? (CHECK ONE RESPONSE ONLY) a. trial and error by m yself b. learned or helped by a friend c. learned or helped by a relative d. learned or helped by paying so m e o n e e. other (describe)________________________________________ 3. Do you feel that learning to do this new thing effected you in any of the following ways? (CHECK ALL THAT APPLY) a. feel better about m yself b. be more independent c. keep busy d. deal better with the lo ss of my sp o u se e. get along better with others f. anything else? (describe)_______________________________ 4. Do you feel that not being able to d o this task m ad e it m ore difficult for you to cop e with your sp o u s e ’s death? (CHECK ONE ONLY) a. Yes, a lot m ore difficult b. Yes, som ew hat more difficult c. Yes, but only a little bit m ore difficult d. No, it h asn ’ t m ade it m ore difficult Is there any other asp ect of your daily life and routines that has not been covered by the ab ove survey that you feel has significantly ch an ged sin ce the death of your sp o u se? (Please explain)___________________________________________________________________________ (U se the back of the p age if you n eed to) 173 This checklist of item s deals with your feelin gs about your life. After reading each statem ent, indicate whether you Agree or Disagree with it by checking the appropriate box. Agree Disagree jj 1. As I grow older, things seem better than I thought they would be. 2. I have gotten more of the breaks in life than most of the people I know. 3. This is the dreariest time of my life. 4. I am just as happy as when 1 was younger. 5. My life could be happier than it is now. 6. These are the best years of my life. 7. Most of the things 1 do are boring and monotonous. 8. 1 expect some interesting and pleasant things to happen to me in the future. 9. The things 1 do are as interesting to me as they ever were. 10. I feel old and somewhat tired. 11. I feel my age, but it doesn’t bother me 12 As I look back on my life, I am fairly well satisfied. 13. I would not change my past life even if I could. 14 Compared to other people my age, I've made a lot of foolish decisions in my life. 15. Compared to other people my age, I make a good appearance. 16. I have made plans for things I'll be doing a month or year from now. 17. When I think back over my life, I didn't get most of the important things I wanted. 18. Compared to other people, I get down in the dumps too often. 19. I've gotten pretty much what I expected out of life. 20. In spite of what people say, the lot of the average person is getting worse, not better. 174 Now we would like to find out about so m e skills or abilities that you m ay or may not have For each ability that is m entioned, p lease indicate to what extent you think you p o sse ss that ability: Not at all, Somewhat, or A lot. Not at all Somewhat A lot I 1. Ability to plan and cook meals that you know are nutritious for yourself and for your family. 2. Ability to drive a car. 3. Ability to do minor mechanical repairs. 4. Ability to organize your time and use it effectively. 5. Ability to be assertive-to make requests of others and to say "no" when you need to without being overly aggressive. 6. Ability to exercise self-control--to direct or restrain your actions in order to achieve your goals. 7. Ability to do math problems-such as those necessary to balance your checkbook. 8. Ability to cope with failures--to experience setbacks or frustrations without losing confidence or hope. 9. Ability to adapt--to adjust readily to different or changing conditions. 10. Ability to set goals objectively-to decided what you what realistically, taking into account what you need, what the people around yoj need, and what you can and cannot do. 11. Ability to manage finances~to budget wisely, to avoid financial difficulty by anticipating how you will handle expenses. 12. Ability to identify resources-to find the people, friends, or agencies that can help you meet you needs. 175 Not at ail Somewhat A lot 13. Ability to organize and utilize the sources of help you have identified. 14. Ability to understand your own leisure needs and to meet them. 15. Ability to appreciate, take part in. or act with a sense of humor. 16. Ability to perform and endure the physical activities that are required of you during the day. 17. Ability to plan things in advance. 18. Ability to speak honestly and fluently about yourself-to express your thoughts, feelings, and desires in a way that allows people to understand and know you. 19. Ability to learn about and use public transportation. 20. Ability to keep your household organized and clean. 21. Ability to learn about and use, when necessary, public facilities and services, such as the fire station, police station, hospital, etc. 22. Ability to concentrate-to focus and keep your attention on what you are doing. 23. Ability to recognize interpersonal problems--to understand the nature and source of whatever difficulties you may have in your relations with others. 24. Ability to understand quickly and adequately what people communicate to you--not only through their words, but also through their facial expressions, the way they stand, etc. 25. Ability to understand and anticipate how other people will react to your actions-the things you say or do. THANK YOU VERY MUCH FOR FILLING OUT THIS QUESTIONNAIRE!! Would you be willing to be interviewed at a later date? YES________________ NO______________ NOT SURE___________ P lease list your nam e and p h on e num ber if you would b e willing. NAME____________________________ PHONE Again, all information you have given will b e kept confidential. 177 Appendix F: Tables of Analyses Results Table FI Gender Comparison for Variables Using Chi-Square Variables____________________ Male____ Female Chi-Sq Religious Membership 1.41 Catholic 1 9 LDS (Mormon) 24 73 Protestant 2 10 None 1 3 Belief in After Life - At Death of Spouse 13.65 No 0 1 Uncertain 9 6 Yes 19 87 Belief in After Life - At 2 Years 1.89 No 12 47 Uncertain 2 2 Yes 14 45 Living Arrangements - At 2 Years 18.05 Alone 11 40 With Child(ren) 0 10 With Relative 0 1 Remarried 5 1 Other Arrangement 1 0 p-value .704 . 001* . 388 .001* 178 Table FI continued Variables___________________ Male____Female Chi-Sa Living Arrangements - At 8 Years 16.43 Alone 14 59 With Child(ren) 0 12 With Relative 0 3 With Friend 0 1 Remarried 10 8 Other Arrangement 2 7 Perceived Financial Status .56 Problematic 3 14 Comfortable 20 66 More than comfortable 3 7 Spouse's Death Slow/Sudden .21 Slow 11 47 Sudden 13 45 Spouse's Death Expected 2.72 Expected 13 60 Unexpected 15 34 p-value .006* .757 .647 .099 179 Table F2 Males Females Variable N M SD N M SD t D--value Age 28 67.7 6.7 94 65.0 8.1 1.78 .08 Education 28 2.7 1.1 94 2.8 .9 -.36 .72 # Children/DOS 28 3.5 1.9 94 3.5 2.0 -.10 .92 # Children/8 yrs 26 3.5 2.0 88 3.2 1.6 .52 .60 Children/50ml/DOS 27 2.6 1.7 89 2.5 1.8 .10 .92 Children/50ml/8 yr 26 2.3 1.6 90 2.3 1.6 .24 .81 Long Illness 27 2.7 1.0 90 2.8 .9 -.49 .63 Coping/DOS 27 5.0 1.5 93 5.6 1.1 -1.95 .06 Coping/2 yrs 28 4.4 1.9 94 4.4 1.5 .09 .93 Coping/8 yrs 25 5.2 1.4 90 5.7 1.1 -1.70 .10 Satisfac/Cope/2 yr 28 4.4 2.0 94 4.3 1.7 .22 .83 Satisfac/Cope/8 yr 25 5.5 1.4 90 5.7 1.3 -.71 .48 Loneliness/DOS 27 5.6 1.4 92 4.8 1.7 2.48 .01* Loneliness/8 yrs 24 3.9 1.6 90 3.8 1.5 .08 .93 Self-esteem1/DOS 27 5.3 1.2 93 5.3 1.3 .10 .92 Self-esteem1/2 yr 28 4.7 1.8 94 4.5 1.4 .52 .60 Self-esteem1/8 yr 25 5.7 1.3 90 5.7 1.3 .08 .94 Self-esteem2/DOS 28 32.5 4.0 94 31.8 5.1 .76 .44 Self-esteem2/2 yr 28 26.7 10.0 94 25.2 9.1 .82 .42 Self-esteem2/8 yr 23 34.1 4.6 85 33.6 4.1 .56 .58 Life Satisfac/DOS 28 13.1 4.1 90 13.9 3.7 -.91 .37 Life Satisfac/2 yr 28 8.0 8.2 94 7.2 8.0 0.45 .65 180 Table F2 continued Males Females Variable____________ N____ M____ SD N____ M____ SD____ t p-value Life Satisfac/8 yr 26 13 .1 5.1 89 14.4 4.0 -1.21 .24 Depression/DOS 28 9.9 7.8 94 9.5 7.5 .22 .83 Depression/2 yr 28 2.7 6.3 94 2.8 4.8 .09 .93 Depression/8 yr 26 6.2 6.8 89 6.2 5.9 .03 .97 Health/2 yr 27 5.1 1.0 94 4.9 1.1 1.08 . 29 Health/8 yr 25 4.6 1.6 89 5.0 1.3 -1.22 . 23 Competency/DOS 28 58.8 8.8 94 56.5 7.6 1.23 . 23 Competency/2 yr 27 53.1 12. 2 94 55.5 9.2 -.96 . 34 Competency/8 yr 26 55.1 11.7 90 58.1 7.5 -1.55 .12 Note: DOS = At death of spouse, 1 = Likert scale 2 — / Rosenberg Scale, 50ml = within 50 miles. Alpha < .01. 181 Table F3 Comparison of Variables For Participants and Non-Participants Using Chi-Square Variables Part Non-Part Chi-Sq Gender Male Female Race Caucasian Native American 28 94 122 0 28 72 99 1 .80 1.24 Living Arrangements - At 2 Years Alone 51 43 With Child(ren) 10 9 With Relative 1 3 Remarried 6 2 Other Arrangement 1 3 10.16 Religious Membership Catholic LDS (Mormon) Protestant Other None 4.21 10 96 12 0 4 7 77 11 3 2 p-value .370 .266 .071 .378 182 Table F3 continued Variables____________________Part___ Non-Part Chi-Sq Belief in After Life - At Death of Spouse .28 No 1 1 Uncertain 15 10 Yes 106 89 Belief in After Life - At 2 Years 3.72 No 59 41 Uncertain 4 9 Yes 59 49 Spouse's Death Slow/Sudden .10 Slow 58 47 Sudden 58 4 3 Spouse's Death Expected .08 Expected 73 58 Unexpected 49 36 p-value .868 .156 .752 .781 183 Table F4 Comparison of Variables Between Participants and Non-Participants Using t-tests Participants Non-Particip. Variable N M SD N M SD t p--value Age 122 65.6 7.9 99 67.7 8.1 -1.95 .05 Education 122 2.8 1.0 100 2.6 1.0 1.97 .05 # Children/DOS 122 3.5 2.0 99 3.6 1.9 -.05 .96 Children/50ml/DOS 116 2.5 1.8 98 2.3 1.6 .95 . 34 Long Illness 117 2.8 .9 92 2.8 .9 .03 .98 Coping/DOS 120 5.5 1.2 99 5.3 1.3 1.06 . 29 Coping/2 yrs 122 4.4 1.6 99 4.6 1.5 -1.09 .28 Satisfac/Cope/2 yr 122 4.4 1.7 99 4.4 1.7 -.19 .85 Loneliness/DOS 119 5.0 1.7 99 5.2 1.6 -1.05 .29 Self-esteem1/DOS 120 5.3 1.2 99 5.2 1.4 . 24 .81 Self-esteem1/2 yr 122 4.5 1.5 99 4.5 1.5 .11 .92 Self-esteem2/DOS 122 31.9 4.8 99 32.3 4.7 -.60 .55 Self-esteem2/2 yr 122 25.7 9.3 96 27.0 8.6 -1.16 .25 Life Satisfac/DOS 122 57.0 7.9 97 56.9 8.0 .15 .88 Life Satisfac/2 yr 122 7.4 8.0 99 8.2 7.4 -.78 .44 Depression/DOS 122 9.6 7.5 99 9.1 7.4 -.33 .74 Depression/2 yr 122 2.8 5.1 99 5. 37 . 3 -2.92 .004* Health/2 yr 122 4.9 1.1 99 4.9 1.1 . 53 .60 Competency/DOS 122 57.0 7.9 97 56.9 8.0 .15 .87 Competency/2 yr 122 55.0 9.9 95 55.3 10.0 -.22 .82 Note: DOS = At death of spouse, 1 = Likert scale, 2 = Rosenberg Scale, 50ml = within 50 miles. Alpha < .01. DF were between 194 and 219. 184 Table F5 Comparison of Variables For Participants and Deceased Chi-Square Variables_____________________Part Non-Part Chi-Sq Gender 3.74 Male 28 15 Female 94 24 Race Caucasian 122 39 Living Arrangements - At Alone With Child(ren) With Relative Remarried Other Arrangement Years 6.08 51 16 10 2 1 2 6 0 1 1 Religious Membership Catholic LDS (Mormon) Protestant Other None 7.95 10 96 12 0 4 2 31 4 2 0 p-value .053 .193 .094 185 Table F5 continued Variables__________________Part Non-Part Chi-Sq Belief in After Life - At Death of Spouse .76 No 1 1 Uncertain 15 5 Yes 106 33 Belief in After Life - At 2 Years 3.37 No 59 18 Uncertain 4 4 Yes 59 16 Spouse's Death Slow/Sudden .55 Slow 58 20 Sudden 58 15 p-value .682 .186 .459 Spouse's Death Expected .02 .891 Expected 73 22 Unexpected 49 14 186 Table F6 Comparison of Variables Between Participants and Deceased Using t tests Participants Deceased Variable N M SD N M SD t p-valu( Age 122 65.6 7.9 39 70.3 8.1 3.21 .002* Education 122 2.8 1.0 39 2.7 1.0 -.67 .50 # Children/DOS 122 3.5 2.0 38 3.8 2.2 .64 .53 Children/50ml/DOS 116 2.5 1.8 38 2.6 1.5 .09 .93 Long Illness 117 2.8 .9 33 2.7 1.1 -.60 .55 Coping/DOS 120 5.5 1.2 38 5.1 1.3 -1.51 .14 Coping/2 yrs 122 4.4 1.6 38 4.7 1.4 1.08 .28 Satisfac/Cope/2 yr 122 4.4 1.7 38 4.3 1.5 -.07 .95 Loneliness/DOS 119 5.0 1.7 38 5.3 1.5 1.22 .23 Self-esteem1/DOS 120 5.3 1.2 38 5.0 1.4 -.96 .34 Self-esteem1/2 yr 122 4.5 1.5 38 4.5 1.3 -.09 .93 Self-esteem2/DOS 122 31.9 4.8 38 32.6 5.0 .73 .47 Self-esteem2/2 yr 122 25.7 9.3 36 27.1 7.8 .91 .36 Life Satisfac/DOS 122 57.0 7.9 38 13.4 4.5 -.42 .67 Life Satisfac/2 yr 122 7.4 8.0 38 7.3 7.3 -.12 .91 Depression/DOS 122 9.6 7.5 38 10.0 7.0 .30 .77 Depression/2 yr 122 2.8 5.1 38 5.5 7.9 2.49 .01* Health/2 yr 122 4.9 1.1 38 4.9 .8 -.19 .85 Competency/DOS 122 57.0 7.9 38 56.3 7.7 -.34 .74 Competency/2 yr 122 55.0 9.9 35 53 .1 9.4 -1.04 .30 Note: DOS = At death of spouse, 1 = Likert scale, 2 = Rosenberg Scale, 50ml = within 50 miles. Alpha < .01. DF were between 194 and 219.

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Asset Metadata

Creator Wright, Joanne (author)

Core Title Occupational restructuring by and selected psychological characteristics of older adults after the death of their spouse

Degree Doctor of Philosophy

Degree Program Occupational Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, guidance and counseling,Gerontology,health sciences, rehabilitation and therapy,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Zemke, Ruth (committee chair), Neville-Jan, Ann (committee member), Peterson, David A. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-610144

Unique identifier UC11226930

Identifier 9617006.pdf (filename),usctheses-c20-610144 (legacy record id)

Legacy Identifier 9617006.pdf

Dmrecord 610144

Document Type Dissertation

Rights Wright, Joanne

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA