Philadelphia College of Osteopathic Medicine DigitalCommons@PCOM PCOM Psychology Dissertations Student Dissertations, Theses and Papers 2009 Social Support as a Moderator between Health Status and Self-Esteem, Psychosocial Stress, and Mood in Old Order Amish Women Christina L. Abbott Philadelphia College of Osteopathic Medicine, clabbott@hacc.edu Follow this and additional works at: http://digitalcommons.edu/psychology_dissertations Part of the Clinical Psychology Commons Recommended Citation Abbott, Christina L., "Social Support as a Moderator between Health Status and Self-Esteem, Psychosocial Stress, and Mood in Old Order Amish Women" (2009). PCOM Psychology Dissertations. This Dissertation is brought to you for free and open access by the Student Dissertations, Theses and Papers at DigitalCommons@PCOM.
It has been accepted for inclusion in PCOM Psychology Dissertations by an authorized administrator of DigitalCommons@PCOM. For more information, please contact library@pcom. Philadelphia College of Osteopathic Medicine Department of Psychology SOCIAL SUPPORT AS A MODERATOR BETWEEN HEALTH STATUS AND SELF-ESTEEM, PSYCHOSOCIAL STRESS, AND MOOD IN OLD ORDER AMISH WOMEN By Christina L. Abbott Submitted in Partial Fulfillment of the Requirements of the Degree of Doctor of Psychology September 2009 PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE DEP ARTMENT OF PSYCHOLOGY Dissertation Approval This is to certify that the thesis presented to us by ( I.
,Ii hJ~ #- L DS , 20- , , in partial fulfillment of the requirements for the degree of Doctor of Psychology, has been examined and is acceptable in both scholarship and literary Committee Members' Signatures: Donald Masey, Psy., Chairperson Virginia Salzer, Ph. Karen Lindgren, Ph., ABPP, Chair, Department of Psychology iii Acknowledgements I want to thank my loving husband Berwood for his unfailing support, insight and guidance, my stepchildren Hannah and Spenser for their patience and understanding, and my mother Loretta Rogers, for her unwavering love and support. This accomplishment is as much theirs as it is mine, and I will be forever grateful. iv Abstract The Amish population is growing in Lancaster County, Pennsylvania (Kraybill, 2008) and Amish use of medical and psychological services provided by the outside world is increasingly common (Cates & Graham, 2002; Weyer et al.
Yet, little is known about how Amish women perceive their health status or how these variables interact in this population. This study revealed an identifiable relationship between health status and psychological functioning in 288 Amish women, ages 18 to 45. As health improves, self- esteem and mood also improve. Of greater importance is the fact that when good social support is available, even Amish women in poor health report high self-esteem.
v Table of Contents Acknowledgements. iv List of Tables………………………………………………………………………. viii Chapter One: Introduction…. 1 Statement of Problem…………………………………………………….
1 Purpose of the Study……………………………………………………. 3 Relevance to Better Understanding the Amish…………………………. 4 Chapter Two: Literature Review…………………………………………………… 5 Relevant Constructs ……………………………………………………. 8 Relationship Between Health Status and Psychological Functioning…… 8 Health Status and Depression………………………………….
8 Health Status and Self-Esteem…………………………………. 10 Health Status and Psychosocial Stress…………………………. 13 Role of Social Support in Moderating Psychological Functioning……… 17 Physical and Mental Health Functioning in the Amish…………………. 18 Amish and Physical Health…………………………………….
19 Amish and Mental Health……………………………………. 21 Social Support Among the Amish………………………………………. 25 Chapter Three: Hypotheses………………………………………………………… 28 Hypotheses/Research Questions………………………………………… 28 Statement of the Hypotheses……………………………………………. 31 Chapter Four: Methods…………………………………………………………….
33 Sample Selection………………………………………………………… 34 Recruitment……………………………………………………………… 34 Response Rate…………………………………………………………… 35 Measures…………………………………………………………………. 35 Functional Health Status………………………………………. 35 Objective Health Status………………………. 39 Analysis of Risk/Benefit Ratio………………………………….……… 40 Procedures for Maintaining Confidentiality…………………………….
40 Chapter Five: Results…………. 47 vii Chapter Six: Discussion. 49 Summary and Significance of Findings…………………………………. 49 Contributions of the Study……………………………………………….
53 How Can We Better Serve the Amish?.………………………………… 55 Limitations of the Study…………………………………………………. 57 Directions for Future Research…………………………………………. Short Form-12 Survey (SF-12v2™)…………………………………. Chronic Health Conditions……………………………….
MOS Social Support Survey…………………………………………. Center for Epidemiologic Studies Depression Scale…………………. Psychosocial Profile Hassles Scale…………………………………… 77 F. Rosenberg Self-Esteem Scale……………………………………….
78 viii List of Tables Table 1 Comparison of Internal Consistency Estimates Between the Current Study and the Original Studies……………………………………………………………. 41 Table 2 Means and Standard Deviations for Key Measures………………………. 42 Table 3 Moderated Multiple Regression Results for Self-Esteem…………. 45 Table 4 Moderated Multiple Regression Results for Depression.
46 Table 5 Moderated Multiple Regression Results for Stress……. 47 Table 6 Frequency of Responses to the Psychosocial Profile Hassles Scale………. 49 Social Support as a Moderator Between Health Status and Self-Esteem, Psychosocial Stress, and Mood in Old Order Amish Statement of Problem There are approximately 220,000 Amish people living in twenty-seven states across America and Ontario, Canada (Kraybill, 2008). The largest Amish settlement is located in Holmes County, Ohio.
The second largest settlement is located in Lancaster County, Pennsylvania. Lancaster’s settlement is the oldest and most densely populated. An estimated 27,000 Amish reside in Lancaster County, half of whom are under the age of 18. Although many non-Amish believe that the Amish population is slowly dying out, this is not the case.
In fact, during the past century the Amish population has doubled in size approximately every twenty years. The rapid growth in the Amish population is attributed to their robust birth and retention rates (Kraybill, 2008). The average Amish family has seven children. The number of adults who leave the Amish community or youth who choose not to be baptized is less than 10 percent (Kraybill, 2008).
The life expectancy for the Amish is 70.6) years (Mitchell et al., 2001); unlike men and women in the general population, Amish men live as long as Amish women (Miller, 1980). Amish population growth is also attributed to the community’s ability to resist the forces of modernization that threatened their cultural beliefs, yet simultaneously accepting select technology that perpetuates their society. Like many other Amish communities, the Lancaster County Amish shun most modern day conveniences. They use the horse and buggy for transport, do not own televisions, prohibit higher education, and do not use electricity in the home (Ediger, 2005; Hostetler, 1993; Kraybill, 2008).
Social Support 2 However, unlike some Amish communities, Lancaster County Amish are permitted to ride in the cars of others, use public telephones, and selectively use diesel generators in workshops and barns (e., automatic milking machines). Although the Amish have constructed a cultural barrier between themselves and the outside world, they are not completely devoid of interaction with that world. In fact, the Amish frequently interact with their non-Amish neighbors. For example when the Amish need medical or psychological services, they must rely on the outside world to provide these services (Hostetler, 1993).
The Amish also have frequent commercial interactions with the non-Amish through the sale of goods and services (Kraybill, 2001). Health status can have a profound effect on psychological functioning in the general population (Carney, 1998; Carney, Freedland, Eisen, Rich, & Jaffe, 1995; Ciechanowski, Katon, & Russo, 2000; Fishbain, 1999; Katon, 2003; DiMatteo, Lepper, & Croghan, 2000). A large body of research also suggests social support moderates the effect of health status on psychological functioning (Cassel, 1976; Cobb, 1976; Cohen & Wills, 1985; Fusilier & Manning, 2005; Uchino, Cacioppo, & Kiecolt-Glaser, 1996; Vandervoort, 1999). Understanding these relationships allows physicians to better address the needs of their patients and to promote a biopsychosocial approach to treatment.
However, it is not known if these same relationships exist in the Amish population or how these relationships impact the Amish because few empirical studies on the physical and mental health of the Amish have been conducted. Much of what is published is out-of-date, relies on anecdotal information, or has limited scientific rigor (Thomas, Menon, Ferguson, & Hiermer, 2002). Social Support 3 Purpose of the Study The purpose of this study is to determine whether or not a relationship exists between health status and psychological functioning, specifically self-esteem, mood, and psychosocial stress, in a subset of the Amish population (Amish women between the ages of 18 and 45), and to determine how social support moderates this relationship. Because the Amish population is expected to grow significantly, efforts to increase cultural competence in relation to this unique group must be made in order to improve service delivery.
Although research indicates that health status is related to psychological functioning in the general population (Carney, 1998; Carney, Freedland, Eisen, Rich, & Jaffe, 1995; Ciechanowski, Katon, & Russo, 2000; DiMatteo, Lepper, & Croghan, 2000; Fishbain, 1999; Katon, 2003), this research has not been extended to the Amish population. There is no evidence that the Amish are significantly healthier than their non- Amish counterparts or are less susceptible to psychological dysfunction (Cassady, Kirschke, Jones, Craig, Bermudez, & Schaffner, 2005; Colbert, 1980; Fuchs, Levinson, Stoddard, Mullet, & Jones, 1990; Miller et al., 2007; Weyer et al. The area in which the Amish appear to differ is in their strong social networks. According to Kraybill, Nolt & Weaver-Zercher (2007), the typical Amish person has more than 75 first cousins, most of these living within a short distance of each other, who when needed, mobilize to assist family members in crisis.
In case of fire, illness or death, community and family members take over daily chores, prepare food, care for young children, and offer prayers and words of comfort. The process appears seamless when such tragedy occurs. Social Support 4 The question is whether or not this social support affects psychological functioning when the Amish are in poor health. Another concern is whether or not the Amish receive the same level of social support for less obvious everyday limitations, such as a health problem, as they do for obvious tragedy.
In fact, because Amish culture relies much less on technology and is more agriculturally based, limited physical health may be more damaging to the Amish person. The Amish lifestyle requires robust health; great value is placed on completing a good day’s work. According to Hostetler (1993), “the Amish emphasize hard work, and for them, a healthy person is one who has a good appetite, looks physically well, and can do rigorous physical labor. A poor appetite means poor health” (p.
Relevance to Better Understanding the Amish There is a paucity of empirical research on the associations between physical and psychological functioning in the Amish. Given the rapid growth of this population and its reliance on non-Amish physicians and mental health providers, additional research is needed to understand the Amish view of physical and mental health, including how specific cultural elements, such as its social system, interact on these processes. This study will increase this understanding and may help improve service delivery to this unique population. Social Support 5 Chapter Two: Literature Review Relevant Constructs Health Status In 2005, 133 million Americans were living with at least one chronic condition, a 48% increase from 1987 (National Center for Chronic Disease Prevention and Health Promotion, 2009; Hoffman, Rice, & Sung, 1996).
According to Paez, Zhao, and Hwang (2009), the prevalence of self-reported chronic illness is increasing among individuals of all ages. More than 33 million Americans living with at least one chronic illness are between the ages of 20 and 44, and 71 million of these are women. Direct medical costs totaled more than $1.5 trillion in 2005; this is an increase from $425 billion in 1990 (CDC, 2009; Hoffman, Rice, & Sung, 1996). Indirect costs are more difficult to calculate if one considers the impact that chronic illness and health status has on psychological functioning.
The World Health Organization (1948) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, which suggests that health has at least three elements: physical health, mental health, and a social component. Some researchers believe the definition of health should be restricted to include only physical and mental components. Ware, Brook, Davies, and Lohr (1981) caution against the inclusion of social functioning; they believe that it “extends the concept of health beyond the individual to include the quantity and quality of social contacts and social resources” (p. According to the WHO definition of health, a change in social support (e., loss of a loved one or geographical separation from family and friends) implies a change in health status.
Ware et al.