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K. J. Ajrouch
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et al.:
26 (1)
Social
© 2013
Relations
Hogrefe
inPublishing
Lebanon
Full-Length Research Report
Stress, Social Relations,
and Psychological Health
Over the Life Course
A Focus on Lebanon
Kristine J. Ajrouch1, Sawsan Abdulrahim2, and Toni C. Antonucci3
1
Department of Sociology, Anthropology, and Criminology, Eastern Michigan University, Ypsilanti, MI,
USA, 2Faculty of Health Sciences, American University of Beirut, Lebanon, 3Institute for Social Research
and Department of Psychology, University of Michigan, Ann Arbor, MI, USA
Abstract. This paper documents experiences of stress among people 18+ (N = 500) in Beirut, Lebanon. We investigate the extent to
which social relations function as a stabilizing factor for psychological health. Regression analyses indicate a curvilinear link between
stress and psychological health. Both low and high levels of stress predict higher depressive symptoms. Among those aged 18–39 years,
there is no buffering effect of social relations yet for those aged 40–59 years positive support quality buffers the effect of stress on
depressive symptoms. Among those 60+ years old, negative support quality buffers the effect of stress on depressive symptoms. The
function of social relations varies both in its main and buffering effects at different points in the life course.
Keywords: Lebanon, life course, psychological health, social relations, stress
The phenomenon of aging is drawing increasing attention
worldwide as populations from every corner of the globe
experience a growing proportion of their society living
into old age. Lebanon is a country in the Arab world undergoing a demographic transition that includes declining fertility and high migration rates among younger segments of the population (Abyad, 2001; Sibai, Sen, Baydoun, & Saxena, 2004). Indeed, the age distribution in
Lebanon is expected to change rapidly over the next 40
years, with the number of those aged 65 years and over
predicted to comprise 25% of the country by 2050. Moreover, political instabilities characterizing Lebanon since
its independence in 1943 have undoubtedly served as an
ever-present stressful force over the life course. Older
adults today experienced first-hand the civil war
(1975–1990) as well as ongoing political strife. Such
events not only produce stress, but have additionally diminished the government’s ability to provide security in
old age. As a result, social relations, especially the family, are the major resource available to meet the social
and health needs of older people. Recent political events
continue to impinge on the experiences of all Lebanese,
providing an important context for social relations. War,
DOI 10.1024/1662-9647/a000076
political strife, and migration all serve as a critical backdrop to the aging experience.
Age is of central interest in considering experiences
and effects of stress on psychological health. Older adults
report lower levels of stress than younger adults from both
individual (Birditt & Fingerman, 2003; Windsor & Anstey, 2010) and societal level stressors (Acierno, Ruggiero, Kilpatrick, Resnick, & Galea, 2006; Sabbah, Le Vuitton, Droubi, Sabbah, & Mercier, 2007), yet cumulative
adversity suggests older adults may experience more deleterious effects of stress than younger adults (Dannefer,
2003; Umberson, Williams, Powers, Liu, & Needham,
2006). This paper investigates the prominence of stress
from political instabilities over the life course by examining age-related differences in the extent to which such
events are reported as stressful. We then test whether
stress predicts depressive symptoms, and the degree to
which social relations ameliorate links between stress and
depressive symptoms for young, middle-aged, and older
adults. Our goal is to consider whether social relations
function as a stabilizing factor for psychological health
differentially across the life course.
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K. J. Ajrouch et al.: Social Relations in Lebanon
Figure 1. Expanded convoy model of social relations and stress.
Theoretical Framework
The overarching theoretical framework we employ in this
study builds from the life course convoy model of social
relations (Antonucci, 2001; Kahn & Antonucci, 1980, see
Figure 1). Social relations are multidimensional, including
network structure, support type, and support quality. Convoys are dynamic and lifelong, changing in some ways, but
remaining stable in others, across time and situations. We
extend this conceptualization to include a stress-buffering
component (Antonucci, Ajrouch & Janevic, 2003; Cohen
& Wills, 1985). Social support is often considered a critical
resource that influences psychological health (Antonucci
& Jackson, 1987; Berkman, Glass, Brissette, & Seeman,
2000; Cohen & Syme, 1985). The potential for social relations to offset negative effects of stress has been widely
discussed and demonstrated over the past several decades
(see Thoits, 2010, for a recent review).
Multiple dimensions of stress related to Lebanese political conflict are included in the model as key constructs to
facilitate a comprehensive understanding of links between
context-specific stress and well-being. Personal (age, sex,
etc.,) and situational (country, cultural values, etc.) factors
influence one another, as well as stress, the structure, type,
and quality of social relations and well-being. For instance,
culture-specific value orientations inform the extent to
which the self links with others. Many describe Lebanon
as a country that depends on close connections with others,
especially family, for well-being and for accessing resources (Barakat, 1976; Joseph, 2011; Khalaf, 1971, 2001). We
focus on links between age, stress, social relations, and
well-being for the present investigation (indicated by the
solid lines in Figure 1). A buffering effect signifies key
social relations as a critical resource, attenuating the damaging influence of stress on well-being. For instance, following the tenets of the convoy model, multiple dimensions of social relations are recognized. Social network
GeroPsych 26 (1) © 2013 Hogrefe Publishing
characteristics such as the number of people designated as
close and important and geographic proximity of members
are identified as structural aspects of social relations, and
distinct from positive and negative quality aspects. Each
may potentially influence support exchanges that occur, especially in times of need. Having a large number of close
and important people who live within close geographic
proximity in a network may ameliorate stress because the
need for support can be disbursed among many people –
and hence result in the recipient being buffered from the
negative effects of stress. Moreover, in the presence of high
levels of positive quality support, the effects of stress on
psychological health would be minimized, while in the
presence of high negative support, the effects of stress on
psychological health would be exacerbated. An examination of the convoy model within the context of Lebanon
serves to identify patterns where social relations operate in
ways that support or challenge hypothesized effects of social relations on the stress-psychological health link and
presents one of the first extensions of the convoy model to
consider country and sociopolitical events as situational
characteristics.
Stress and Social Relations
Stressful experiences at the societal level influence health
and the ways that social relations impinge on well-being
(Elder, 1974; Pearlin, 2010). Of particular concern in this
study is how stress is experienced by different age groups.
Whether older adults react more or less to stress continues
to be an issue of debate (see Carstensen, Isaacowitz, &
Turk-Charles, 1999; and Mroczek & Almeida, 2004 for opposing viewpoints), and may play out differently in the
context of political instabilities. Little is known about the
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K. J. Ajrouch et al.: Social Relations in Lebanon
Lebanese experience, which has a unique and varied history. Stress from war in particular may exert unique effects.
Lebanon experienced a civil war from 1975 to 1990, the
effects of which have been identified as the most stressful
sociopolitical event for older adults today (Sibai, Kanaan,
Chaaya, & Campbell, 2007). Whereas the civil war primarily affects those who have lived through it, recent scholarly
works have focused on post memory experiences of the
civil war among Lebanon’s youth, that is, “a recollection
of an event not personally experienced but socially felt”
(Larkin, 2010, p. 618). Moreover, the south of Lebanon was
occupied by Israel from 1982 until 2000, leading to massive internal migrations to the southern suburbs of Beirut
as well as several waves of emigration among youth toward
safer places and in search of economic opportunities. Indeed, changing lifestyles stemming from war and political
strife negatively affected the health of a large proportion of
people for more than a decade (Sabbah et al., 2007). During
the summer of 2006, Lebanon faced a war with Israel,
which led to the destruction of public infrastructures and
private homes. Over one million people (one quarter of the
Lebanese population) were displaced (Yamout & Jabbour,
2010). Finally, on May 7, 2008, Greater Beirut experienced
24 hours of gun-fighting between political factions in Lebanon vying for dominance. The situation quickly abated
with a truce orchestrated by a neutral party (the country of
Qatar), but the threat of another civil war was evident for
the majority of Lebanese. It should also be noted that current political situations in neighboring Arab countries affect political stability in Lebanon. The cumulative impact
of such stress may induce greater negative health effects at
older ages (Dannefer, 2003; Umberson et al., 2006).
Whether or not such experiences are perceived as stressful
differentially across the life course remains an area in need
of examination.
To fully understand how sociopolitical stressors affect
psychological health, it is critical to consider how different
age groups experience these stressors, and moreover how
social relations may serve as key resources under such conditions. A considerable amount of research has examined
the significance of social relations for well-being. This link
was first demonstrated in early empirical work indicating
that social integration decreased the incidence of suicide
(Durkheim, 1951) and mortality across adulthood (Berkman & Syme, 1979). The links between social relations and
health have since been clearly demonstrated (Antonucci &
Jackson, 1987; Cohen & Syme, 1985; House, Landis, &
Umberson, 1988; Stewart & Hays, 1997; Umberson &
Montez, 2010). Close relationships are usually with family
members, i.e., spouse, parents, grandparents, and children.
While these relations are often sources of positive assistance, they can also be the source of frustration, conflict,
and guilt, or at the very least ambivalence (Connidis &
McMullin, 2002; Luescher & Pillemer, 1998). Although
relationships clearly vary in quantity (e.g., number of people in network), it is the quality of relationships that contribute most significantly to well-being (Antonucci, Fuhrer,
17
& Dartigues, 1997; George, Blazer, Hughes, & Fowler,
1989; Oxman, Berkman, Kasl, Freeman, & Barrett, 1992).
Strong, community based affective ties characterize family
relations in Lebanon (Joseph, 1993; Sibai et al., 2004), yet
we know little about the nature of social ties across age
groups, or whether differences regarding social ties vary by
age group.
Social relations hold an added layer of significance in
Lebanon. Socialization within the family circle is highly
encouraged, and indeed social support from immediate and
extended family, as well as friends, provide important resources, and still are considered “the axis of Lebanese values, beliefs and culture” (Farhood et al., 1993, p. 1566; see
also Sabbah, Drouby, Sabbah, Retel-Rude, & Mercier,
2003). In Lebanon, family is an older adult’s main source
of security in later life, with the government offering little
to no support (Abyad, 2001; Sabbah et al., 2007).
Due to the sacred position of family relations in Lebanese society, detailed analyses of social networks as well
as positive and negative aspects of relationships are critical.
Social relations in Lebanon are often described in the aging
literature as an amorphous entity with only positive aspects. We seek to move beyond this somewhat superficial
assessment to distinguish structural characteristics of social
relations from qualitative characteristics, and moreover to
examine both positive and negative quality attributes. In so
doing, we hope to gain a better understanding of how relationships influence stress and psychological health at various points in the life course.
Present Study
Given the importance of understanding age-related differences in experiences of stress, with a specific focus on the
Lebanese context, we tested the following hypotheses:
1) Older adults report more stress overall from political
conflict than do younger adults.
We also explored the following hypotheses for each age
group:
2) High levels of stress from political instabilities predict
higher levels of depressive symptoms.
3) Social relations are associated with psychological
health. With regard to network structure larger networks
and networks that are more geographically proximal
predict lower levels of depressive symptoms. Quality of
social relations influence psychological health so that
high levels of positive quality, and low levels of negative
quality predict lower levels of depressive symptoms.
According to the moderating hypothesis to be tested, the
quantity and quality of social relations are not necessarily
linked to stress in a systematic way; however, the presence
of these resources among individuals in the most vulnerable groups may mitigate the negative effects on psychological health. The following hypotheses were tested:
4) Network characteristics (network size and geographic
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K. J. Ajrouch et al.: Social Relations in Lebanon
proximity) have no buffering effect on the stress-health
link.
5) The quality of social relations is differentially associated
with stress: Positive quality relationships buffer the
stress-health link, and negative quality relationships exacerbate it.
In sum, the present study investigates the impact of social
relations on the stress-health link among a regionally representative sample of Lebanese at different ages and at different points in the life course.
Methods
Sample
Data are drawn from the Family Ties and Aging Study (see
Abdurahim, Ajrouch, Jammal, & Antonucci, 2012). The
population sampled included the three administrative districts of Beirut in addition to Aley (Choueifat and Aley),
Baabda (e.g., Dahiyeh, Hadath) and Metn (e.g., Borj Hammoud, Sin El Fil, Zalqa). These areas were chosen to represent a sample of geographic clusters from each directorate in Greater Beirut, followed by a random selection of
households within each cluster. Challenges abound in obtaining an accurate demographic profile in Lebanon due to
a political system based on a “delicate sectarian balance,”
whereby data on religion and other social indicators are
highly contentious (El Khoury & Panizza, 2005). The design adopted allowed for a probability sample representative of the age, socioeconomic, and religious diversity of
the population. Data were collected in 2009.
Participants included 500 adults aged 18 years and
above from the greater Beirut area, with an oversampling
of those age 60+. 39% of the sample were aged 60+ (n =
195), approximately 35% were middle aged ranging from
40–59 (n = 174) years old, and the remaining 26% (n = 131)
were young adults between the ages of 18 and 39. Participants completed face-to-face survey interviews done in the
participants’ homes which lasted for approximately an
hour. The overall response rate was 64%.
Measures
Psychological health was measured using an 11-item sum
composite of the Center for Epidemiologic Studies Depression Scale (CES-D) (Cronbach’s α = .86), taken from the
validated Arabic-version 20-item CES-D (Kazarian & Taher, 2010). The CES-D was originally developed in the
United States by Radloff (1977) to screen for depressive
symptomatology. Individual items (“I was bothered by
things that usually don’t bother me”; “I did not feel like
eating: My appetite was poor”; “I felt that I could not shake
off the blues even with help from my family or friends”; “I
GeroPsych 26 (1) © 2013 Hogrefe Publishing
had trouble keeping my mind on what I was doing”; “I felt
depressed”; “I felt that everything I did was an effort”; “I
thought my life had been a failure”; “I felt fearful”; “My
sleep was restless”) were measured by asking if such situations had occurred during the past week, on a scale ranging from 0 (rarely/none of the time) to 3 (mostly/all of the
time). Two positively worded items (“I felt that I was just
as good as other people”; “I felt hopeful about the future”)
were reverse coded.
On stress, respondents were asked to provide a retrospective account of their experience of Lebanese conflicts.
There were a series of questions beginning with the civil
war up to more recent events. Participants were asked:
“How much – if at all – has the civil war (1975–1990)
disturbed your own personal sense of safety and security?
How much – if at all – have the events relating to the conflict between Israel and Lebanon disturbed your own personal sense of safety and security?” “How much – if at all
– has the July 2006 war disturbed your own personal sense
of safety and security?” “How much – if at all – has the
conflict of May 7, 2008 disturbed your own personal sense
of safety and security?” Participants rated their stress using
a 5-point response scale ranging from 1 = not at all; 2 = a
little bit; 3 = moderately; 4 = quite a bit; 5 = extremely.
Participants were also asked to name the Lebanese conflict they deemed most stressful: civil war, July 2006 war,
or May 7, 2008 conflict.
Social relations were assessed in two ways to ascertain
both structure and quality. The structural dimension was
measured using the hierarchical mapping technique (Antonucci, 1986), where participants were shown a diagram of
three concentric circles and the word “you” placed in the
center. Participants were asked to name people closest (inner circle), close (middle circle), and somewhat close (outer circle). The first and last name initials were written on
the diagram in the order indicated by the respondent. Respondents were then asked a series of demographic questions about the individuals included in their social networks.
Total network size represents the number of people the
respondent included on his/her diagram (i.e., inner, middle,
and outer circles combined) with possible values ranging
from 0–17. Information about proximity to the participant
was asked about the first ten people nominated as network
members. Geographic proximity is a dichotomous measure
which assessed whether each network member lives in
Lebanon (yes/no). The proportion of their social network
that lives in Lebanon was calculated, with a possible value
range from 0–1.
The quality of social relations was measured along two
dimensions, positive and negative, reflecting up to seven
key relationships including, spouse, mother, father, child
upon whom they rely most, sibling upon whom they rely
most, best/closest friend, and the first person mentioned in
the diagram (if not already included). Each scale was created by first averaging the items for each relationship and
then averaging all reported relationships in order to mini-
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mize attrition (losing cases who do not have data for all
relationships).
Positive relationship quality was assessed as a mean
composite, with participants asked to state whether they
agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree (1 = disagree; 5 =
agree) with the following five statements: “I can share my
very private feelings and concerns with my (spouse/parent(s)/child/sibling/friend/first person mentioned)”; “I feel
my (spouse/parent(s)/child/sibling/friend/first person mentioned) would help me out financially if I needed it”; “I feel
my (spouse/parent(s)/child/sibling/friend/first person mentioned) would take care of me when I’m sick”; “My
(spouse/parent(s)/child/sibling/friend/first person mentioned) always understands me”; “My (spouse/parent(s)/child/sibling/friend/first person mentioned) always
appreciates the things I do for him/her.” α values ranged
from .60–.88
Negative relationship quality was assessed as a mean
composite, with participants asked to state whether they
agree, somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree (1 = disagree; 5 =
agree) with the following three statements: “My
(spouse/parent(s)/child/sibling/friend/first person mentioned) gets on my nerves”; “My (spouse/parent(s)/child/sibling/friend/first person mentioned) makes
too many demands on me”; “My (spouse/parent(s)/child/sibling/friend/first person mentioned) always
tries to control me or tell me what to do.” α values ranged
from .45–.75.
Control variables included sex and family income. Sex
was coded 1 = male, 2 = female. Family income was measured by asking respondents “Considering income from all
sources – from jobs, remittances, interest, rents, and so
forth – for you and all family members living with you,
what would you say was your total family income last
month?” They were then presented with the following possible categories, and asked to choose: Less than $500,
$501–1000, $1001–2000; $2001–3000, $3001–5000,
$5001–10,000, more than $10,000. Responses were coded
as follows: 1 = less than $500; 2 = $501–$1000; 3 =
$1001–$2000; 4 = $2001–$3000; 5 = $3001–$5000; 6 =
$5001 or more.
Analysis
Descriptive analyses including frequencies, means, and
standard deviations were calculated first to ascertain sample characteristics. Next, analysis of co-variance (ANCOVA) and chi-square tests were carried out to examine
whether or not stress varied by age group, controlling for
sex and family income. Statistically significant age differences in both stress and social relations were evident from
correlations analyses (results available upon request).
Based on the ANCOVA, chi-square tests, and correlation
results, we performed regression analyses separately for
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young (18–39), middle (40–59), and older (60+) adults.
This strategy further allowed for a more parsimonious examination of main and interactive effects of stress and social relations at different points in the life course. To address the research question of whether social relations variables moderate the stress-health link, we conducted a series
of hierarchical regression analyses. At the first step, depressive symptoms were regressed on mean-centered versions
of the independent variables of stress and social relations
with sex and family income included as controls. At the
second step we created interaction terms using the meancentered main variables indicating stress and social relations. Analyses were carried out separately for each of the
three stressful events, testing each interaction effect separately (Jaccard & Turrisi, 2003). If a significant amount of
additional variance is accounted for by the interaction term
in this last step, a moderating or “buffering” effect of the
social relations variable can be inferred.
For each of the main effect models, we examined the
assumption of a linear relationship between the predictor
variables and depressive symptoms using partial-residual
plots (Fox, 1991). Plots indicating possible nonlinear relationships were followed up with subsequent testing by
power polynomials (Cohen, Cohen, West, & Aiken, 2003).
Specifically, we entered higher order (i.e., quadratic and
cubic) terms into the regression equation in a hierarchical
fashion to assess whether their addition improved the fit of
the model. Polynomials resulting in significant improvements to the model were included in the final main effects
model. Interactions involving nonlinear main effects were
tested with both the lower order (linear) and higher order
(quadratic or cubic) terms. We then plotted graphs using
one standard deviation above (to indicate high support
quality) and below (to indicate low support quality) the
mean social relations score.
Results
Characteristics of the sample are presented in Table 1 and
include the means and sample distribution of age, sex, and
income as well as marital status, social relations, and depressive symptoms. Descriptive statistics are reported for
the total sample as well as by age group. In the total sample,
the average age of participants was just under 52 years (SD
= 17.6); 51% of the sample was women. Approximately a
fifth of the total sample reported income of less than
$500/month (the official minimum wage in Lebanon), a
little over half reported an annual household income of between $500–$1000/month, and a little over one quarter of
the overall sample reported a household income of more
than $1000/month. More than half (58%) of the sample
were married. Respondents reported an overall network
size of 5.5 (SD = 2.8), and almost 91% of their network
lived in Lebanon. They reported mean positive relationship
quality of 4.6 (.5) and mean negative relationship quality
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Table 1. Sample characteristics
Total
Age 18–39
Age 40–59
Age 60+
(N = 500)
(N = 131)
(N = 174)
(N = 195)
M (SD)
Age (18–91)
% (N)
52 (17.6)
Women
M (SD)
% (N)
30 (5.8)
51 (255)
M (SD)
% (N)
M (SD)
50 (5.7)
% (N)
70 (7.6)
48 (63)
52 (90)
52 (101)
Income
< $500/mo.
19 (90)
6 (8)
15 (25)
30 (57)
$500–$1000/mo.
53 (257)
55 (69)
53 (89)
53 (99)
17 (32)
> $1000/mo.
28 (153)
39 (49)
32 (54)
Married
58.4 (292)
57.3 (75)
69.5 (121)
Total Network Size
% Network in Lebanon
49.2 (96)
5.5 (2.8)
5.2 (2.1)
4.9 (2.6)
6.1 (3.3)
88.2 (24.9)
90.6 (22.0)
94.3 (15.4)
90.5 (22.4)
Positive relationship quality
4.6 (.5)
4.5 (.4)
4.6 (.5)
4.7 (.5)
Negative relationship quality
1.6 (.6)
1.7 (.6)
1.7 (.6)
1.4 (.5)
Depressive symptoms (0–33)
10 (7.9)
7.2 (7.3)
10.6 (8.5)
11.3 (7.3)
Table 2. ANOVAs of stressful life events evaluations by age group controlling for sex and income (N = 500)*
Stressful life events
The civil war (1975–1990)
(Adj. R2 = .27)
Age
(1)
(2)
(3)
18–39
40–59
60+
(N = 131)
(N = 174)
(N = 195)
2.7 (1.5)
4.2 (1.2)
4.5 (1.0)
4.0 (1.3)
4.0 (1.2)
4.0 (1.2)
3.0 (1.5)
3.4 (1.5)
3.4 (1.4)
F(2, 471) = 80.77, p = .000
Posthoc sign. p < .05: 1 v 2; 1 v 3; 2 v 3
The July 2006 war
(Adj. R2 = .01)
F(2, 472) = .10, p = .907
Posthoc sign. p < .05: none
The conflict of May 7, 2008
(Adj. R2 = .01)
F(2, 471) = 2.75, p = .065
Posthoc sign. p < .05: 1 v 3 (p = .05)
Note. *Posthoc comparison of 1, 2, and 3, refer to age groups 18–39, 40–59, and 60+ years, respectively.
of 1.6 (.6). The average depressive symptom (CES-D)
score was 10 (SD = 7.9).
Age patterns in the demographics of interest provide important insights. Among those between the ages of 18–39,
the average age was 30 (SD = 5.8), and 48% were women.
Some 6% of those aged 18–39 reported income of less than
$500/month, a little over half reported an annual household
income of between $500–$1000/month, and almost 40% of
the 18–39 sample reported a household income of more
than $1000/month. The average total network size was 5.2
(SD = 2.1), and more than 94% of their network lived in
Lebanon. Respondents 18–39 rated positive aspects of their
relationships 4.5 (SD = .4), and negative aspects 1.7 (SD =
.6). The average depressive symptom score for those aged
18–39 was 7.2 (SD = 7.3). Among those between the ages
of 40–59, the average age was 50 (SD = 5.7), and 52% were
GeroPsych 26 (1) © 2013 Hogrefe Publishing
women. About 15% of those aged 40–59 reported income
of less than $500/month, a little over half reported an annual household income of between $500–$1000/month,
and almost one third of the 40–59 sample reported a household income of more than $1000/month. The average total
network size was 4.9 (SD = 2.6), and more than 90% of
their network lived in Lebanon. Respondents 40–59 rated
positive aspects of their relationships 4.6 (SD = .5), and
negative aspects 1.7 (SD = .6). The average depressive
symptom score for those aged 40–59 was 10.6 (SD = 8.5).
Among those aged 60+, the average age was 70 (SD = 7.6),
and 52% were women. About 30% of those aged 60+ reported income of less than $500/month, a little over half
reported an annual household income of between
$500–$1000/month, and 17% of the 60+ sample reported
a household income of more than $1000/month. The aver-
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Table 3. ANOVAs of most stressful life event evaluations by age group controlling for sex and income (N = 500)
Agea
Most stressful life event
(1)
(2)
18–39
40–59
(3)
60+
(N = 131)
(N = 174)
(N = 195)
The civil war (1975–1990)
16% (N = 21)
49% (N = 84)
58% (N = 113)
The July 2006 war
57% (N = 75)
28% (N = 48)
23% (N = 45)
The conflict of May 7, 2008
12% (N = 15)
15% (N = 26)
9% (N = 17)
Otherc
15% (N = 20)
9% (N = 15)
10% (N = 19)
Chi-square test
69.33***
Posthoc analysis (by age group)
18–39 vs. 40–59
42.40***
18–39 vs. 60+
60.89***
40–59 vs. 60+
5.54
Notes. ***p < .001. aColumn percentages are presented so that the percentages within age group total 100%. bA χ² test was conducted to examine
the relationship between Age group and the Most stressful life event. A p-value of .000 indicates a significant difference across the age groups
on which event was the most stressful. Posthoc analyses were conducted to examine all possible pairs of age groups. cRespondents listed as
other (N = 54): all of them (events) (N = 11); Hariri and Saudi Arabia interference (N = 1); Israeli invasion in 1982 (N = 2); none of them (N
= 26); sectarian conflicts in general (N = 14).
age total network size was highest at 6.1 (SD = 3.3), though
they reported the lowest proportion of their network living
in Lebanon (88%). Respondents 60+ rated positive aspects
of their relationships 4.7 (SD = .5), and negative aspects
1.4 (SD = .5). The average depressive symptom score for
those aged 60+ was 11.3 (SD = 7.3). Those in the middle
age group (40–59) were most likely to be married (69.5%),
followed by the youngest age group (57%). Those aged 60+
reported the lowest frequency of being married at just less
than half (49%).
Age and Stress
The hypothesis that older adults report more stress overall
from Lebanese conflicts than younger adults was supported
in part (see Table 2). Interestingly, the age differences were
differentially associated with the specific sociopolitical
stressful event. Age differences, controlling for sex and income, are most prominent regarding the civil war. Posthoc
analyses reveal that older adults rated the civil war as extremely stressful (M = 4.5; SD = 1.0), compared to middleaged adults, who rated the civil war slightly, but significantly, less stressful (M = 4.2; SD = 1.2) and younger adults
who rated it much less stressful (M = 2.7; SD = 1.5). There
were no age differences, however, concerning the July 6
war and May 7, 2008 conflict. In terms of the most stressful
political conflict identified, older and middle-aged adults
reported the civil war as the most stressful event, while
younger adults rated the July 2006 war as the most stressful
event. The most recent political conflict, the May 7, 2008
conflict, was less often rated as most stressful in all age
groups (see Table 3).
Predicting Psychological Health
The hypothesis that high levels of stress from political
instabilities predict a higher level of depressive symptoms was supported. These links varied within each age
group (see Table 5). Results illustrate that, for the youngest age group, the more recent political instabilities (July
2006 war and May 7, 2008 conflict) predicted depressive
symptoms, with a curvilinear association (see Table 4,
Model 1, for those aged 18–39). Those who reported both
low and high levels of stress from each event reported
higher depressive symptoms, while those who reported
moderate levels of stress reported lower depressive
symptoms. In the middle-aged, both the civil war and the
May 7, 2008 conflict predicted depressive symptoms (see
Table 4, Model 1, for those aged 40–59). The association
between stress from the civil war and depressive symptoms was curvilinear. Those who reported either low or
high levels of stress also reported higher depressive
symptoms. On the other hand, the effect of the May 7,
2008 conflict was linear. Those who reported more stress
also reported higher levels of depressive symptoms. Finally, in the oldest age group, those aged 60+, stressful
reactions to the civil war were curvilinearly associated
with depressive symptoms (see Table 4, Model 1 for
those aged 60+). In other words, older adults who reported moderate levels of stress reported experiencing fewer
depressive symptoms than those who reported higher or
lower levels of stress.
The hypothesis that larger, more geographically proximal social networks, with high levels of positive quality
and low levels of negative quality, are associated with lower levels of depressive symptoms was partially supported.
The main effects of social relations on depressive sympGeroPsych 26 (1) © 2013 Hogrefe Publishing
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22
K. J. Ajrouch et al.: Social Relations in Lebanon
Table 4. Impact of sociopolitical stress and social relations on depressive symptoms by age group
Age 18–39
Age 40–59
Age 60+
(N = 120)
(N = 165)
(N = 179)
B
SE
B
SE
B
SE
Controls
Sex
2.09
1.15
.63
1.29
2.64**
.98
–2.26**
.65
–2.38***
.67
–2.68***
.60
.59
.39
–6.96*
3.00
–8.77**
2.90
1.12*
.46
1.34**
.42
July 2006 war
–7.87*
2.99
–.19
.65
–.13
.52
July 2006 war2
1.10*
.44
–6.78**
2.35
1.01*
.51
–.08
.43
1.29**
.38
Size
.20
.29
.23
.26
.27
.15
% Living in Lebanon
.07
.04
–.05
.03
.01
.02
–1.90
1.47
Family income
Stress
Civil war
Civil war
2
May 7, 2008
2
May 7, 2008
Social network
Support quality
Positive
–89.01**
33.46
Positive2
10.09**
3.80
Negative
1.69
1.04
.89
Negative2
.33
Adj. R2
Note. *p < .05, **p < .01, ***p < .001.
.13
1.26
–33.21*
14.12
3.89*
1.66
–13.78*
5.83
4.04*
1.64
.25
Figure 2. Civil war2 × Positive relationship quality among
those 40–59 years old.
Figure 3. Civil war × Negative relationship quality among
those 60 years and older.
toms were evident only for the youngest (18–39) and oldest
(60+) age group, but not the middle (40–59) age group. The
associations were curvilinear. Among those aged 18–39,
low and high levels of positive quality relations predicted
higher depressive symptoms. In other words, if young people felt their relationships with others were either highly
positive or low positive, they were more likely to indicate
experiencing higher levels of depressive symptomology.
This same pattern is evident among those aged 60+ with
both low and high levels of positive quality relations. Interestingly, among people aged 60+, both high and low levels of negative relationship quality was also associated with
higher depressive symptoms.
The structure of social relations (size, geographic proximity) was not significantly associated with depressive
symptoms in any age group.
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Table 5. Sociopolitical stress × social relations interactions on depressive symptoms by age
B
Civil war × Total network size
18–39
40–59
60+
(N = 120)
(N = 165)
(N = 179)
SE
–.09
.19
B
SE
.15
.19
B
SE
.10
.15
Civil war × % living in Lebanon
.04
.02
–.01
.03
.01
.04
Civil war × Positive
.63
1.07
–1.35
1.25
–1.24
1.12
Civil war × Positive2
–.88
3.01
1.33
2.07
Civil war × Negative
–.09
.70
.50
.87
Civil war × Negative2
Civil war2 × Total network size
.33
2
Civil war × % Living in Lebanon
Civil war2 × Positive
.19
1.69
–.13
.12
.02
.03
.05
.04
1.29
.48
.78
.29
.31
.66
.85
–.03
.75
2.00
1.26
.12
Civil war2 × Negative2
July 2006 war × Total network size
.90
.47
–2.87*
Civil war2 × Positive2
Civil war2 × Negative
1.84*
–.12
.21
.00
.20
.07
July 2006 war × % Living in Lebanon
.03
.02
.02
.04
–.02
.02
July 2006 war × Positive
.26
1.10
.29
1.19
–.59
.94
July 2006 war × Positive2
–2.92
2.63
.35
1.55
July 2006 war × Negative
–.07
.69
.12
.84
.76
.68
.60
1.16
–.03
.21
.11
2
July 2006 war × Negative
July 2006 war2 × Total network size
July 2006 war2 × % Living in Lebanon
.02
.03
July 2006 war2 × Positive
–.77
1.03
July 2006 war2 × Positive2
–.07
.12
2
July 2006 war × Negative
.90
.66
–.10
.21
.15
.16
.07
.02
.02
–.04
.02
.00
.02
May 7, 2008 × Positive
–.21
.91
.24
1.00
–.24
.82
May 7, 2008 × Positive2
1.57
2.48
–.49
1.11
May 7, 2008 × Negative
–.02
.58
May 7, 2008 × Total network size
May 7, 2008 × % Living in Lebanon
May 7, 2008 × Negative2
May 7, 20082 × Total network size
May 7, 20082 × % Living in Lebanon
–.03
–.49
.78
1.13
.67
.15
1.06
.17
.01
.03
May 7, 20082 × Positive
–.14
.80
May 7, 20082 × Positive2
.43
.42
May 7, 20082 × Negative
.43
.60
Notes. Each interaction was tested in a separate regression model controlling for all main effects. For interactions with quadratic terms, all lower
order terms were included as controls. *p < .05, **p < .01, ***p < .001.
Social Relations as a Buffer
Based on results of the initial analyses, testing the buffering
hypotheses was only examined in relation to the stress indicator that significantly predicted psychological health
within each age group (see Table 5). In the youngest age
group (18–39), social relations exerted no buffering effect.
In the middle-aged group (40–59) a significant interaction
(p < .05), arose with regard to positive quality relations.
Those with high positive quality report relatively stable and
low levels of depressive symptomology, regardless of
stress level, indicating a buffering effect (see Figure 2).
Finally, in the oldest age group (60+), a significant interaction (p < .05), arose with regard to negative quality relations, though the effect was counterintuitive. Those who
rated their relations as highly negative reported relatively
stable, and low, depressive symptoms, regardless of stress
level, indicating a buffering effect of negative quality relations (see Figure 3).
Structure of social relations (size, geographic proximity)
had no interactive effect to ameliorate the effect of stress
on depressive symptoms in any age group.
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K. J. Ajrouch et al.: Social Relations in Lebanon
Discussion
The results of the analysis suggest that (1) the experiences
of stress from sociopolitical events varies with age; (2) sociopolitical stress and social relations are curvilinearly associated with psychological health; and (3) quality of social
relations moderate the association between stress and psychological health. The implications of these findings are
considered below.
Age and Stress
Older adults reported somewhat more stress overall from
political conflict than younger adults. We examined societal stresses that everyone experiences at the same time and
in a similar fashion. It may be that these types of stresses
have a cumulative effect (Dannefer, 2003; Umberson et al.,
2006). The experience of multiple stresses over the life
course intensifies and is evaluated in conjunction with earlier incidents. Moreover, the event labeled most stressful
varied by age, with middle-aged and older adults identifying the civil war as most stressful and younger adults the
July 2006 war. This finding illustrates an intersection between life course and life span development with different
age groups experiencing the same events, yet reporting different reactions. Indeed, it makes sense that experiencing
war at 2 years of age has a different effect than at, say, age
22 or 42. Developmentally, at age 2 the difference between
the occurrence of war and no war may not register the same
as it does for a 22-year-old, whose schooling may be interrupted, or a 42-year-old whose employment opportunities
may disappear. Moreover, the most recent sociopolitical
event, on May 7, 2008, was rated equally stressful by each
age group, which may illustrate a case where cohort, age
and period effects combine to yield the same stress outcomes. The similar stress ratings may be a result of the
recency of the conflict.
Predicting Psychological Health
The hypothesis that high levels of stress from political instabilities predict higher levels of depressive symptoms
was partially supported. Indeed, the association was curvilinear so that both high and low levels of stress predicted
higher levels of depressive symptoms for all age groups.
This finding may signify that those experiencing extreme
reactions (suppressing and/or excessive experiences of
stress) are most vulnerable to poor psychological health.
Indeed, low stress may indicate an inability to experience
any kind of emotions in line with high levels of depressive
symptoms. An average stress reaction, on the other hand,
may help regulate the effects of stress (Lazarus & Folkman,
1984), enabling growth and development (Thoits, 1995).
Similar to the physical benefits (Dhabhar, 2009), moderate
GeroPsych 26 (1) © 2013 Hogrefe Publishing
stress levels may also protect psychological health. It
seems likely that moderate stress reactions reflect a realistic, manageable, and appropriate response.
The effect of social relations on psychological health
varied within the age groups, with a curvilinear main effect
of positive quality on depressive symptoms evident for
both the youngest and oldest age groups. The fact that relationship quality, and not structural aspects of social relations, link to psychological health suggests that quality of
social relations matters most. This supports the notion that
it is not necessarily how many people one lists as close and
important, nor whether they are geographically proximal
that affects psychological health, but rather whether the
quality of support is positive (Antonucci et al., 1997;
George et al., 1989; Oxman et al., 1992). Interestingly,
however, too high or low positive quality does not seem to
be as beneficial as moderate levels of positive quality relations. In the Lebanese context, social relations often reflect
exceedingly close connections that imply an overlapping
sense of self (Ajrouch, Antonucci, Akiyama, & Abdulrahim, 2008). As a result, extremes in positivity may signify
less than optimal social relations, indicating overcompensation for some apparent or displayed vulnerability.
Heightened expectations for closeness in Lebanese ties involve expectations of having some control over another in
a close social relationship (e.g, Joseph, 1993). Low relationship quality (both negative and positive) may also indicate an inability to maintain or achieve control, and hence
present obstacles that results in high levels of depressive
symptoms. Moderate positivity, on the other hand, may indicate a healthy and stable relationship.
Social Relations as Buffer
The buffering effect of social relations varied by age group.
In the youngest age group (18–39), social relations exerted
no buffering effect. It could be that the type of stress most
influential to psychological health in the youngest group,
due to either the nature of the conflict, its duration, or its
recency, simply was not ameliorated by any dimension of
social relations. In addition, the lack of a stress-buffering
effect for the most severe sociopolitical stress, i.e., the civil
war, is likely due to the fact that young people did not rate
this event as highly stressful. This finding is consistent with
the literature indicating that the stronger the stress the more
likely social support buffers the effect of stress on health
(Cohen & McKay, 1984). Further, more recent research
(Birditt, Antonucci, & Tighe, 2012) indicates that, under
conditions of high but not low stress, buffering effects are
more likely to be evident regardless of relationship quality.
Therefore since young people did not rate these sociopolitical events as stressful, it is unlikely that a stress-buffering
effect would be observed. In the middle (40–59) and oldest
(60+) age groups, social relations did moderate the effects
of stress from the civil war on psychological health, though
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K. J. Ajrouch et al.: Social Relations in Lebanon
the dimension of social relations that mattered differed for
each age group.
Positive quality mattered for the middle-aged group.
Middle-aged people, who were young when the civil war
occurred, may benefit most from current positive relations
in that it allows them to manage the stressful memories of
the civil war and thereby recover psychologically. The
fact that positive relationship quality did not buffer the
effects of stress on the psychological health for older
adults may also reflect developmental processes. Older
people who experienced the civil war during their middle
age may only be able to make psychological sense of the
experience by distancing themselves from significant others with whom they disagreed concerning the civil war.
This possibility is particularly relevant considering that
Lebanon remains politically unstable (Joseph, 2011), and
the threat of war is evident on a continual basis (see Larkin, 2010).
Negative quality mattered for the oldest age groups, introducing a counterintuitive finding. Close social relations
in Lebanon, especially within families, incur a quality
where individuals feel interconnected and linked in important ways. Such sentiments are illustrated in that family members often call others by invoking their own
“role.” For instance, a mother may refer to her child as
“mama” or a father refers to his child as “baba” (Joseph,
1993), suggesting an overlapping sense of self (Ajrouch
et al., 2008). Given that older adults perceive close and
important others as extensions of themselves, negativity
in a relationship may pose a profoundly felt stress, difficult to ignore. Moreover, older adults rely on social relations as their primary source of support in old age (Abyad,
2001; Sabbah et al., 2007), signifying that stress from interpersonal relations may be more salient for psychological health than the sociopolitical. Although difficult to interpret definitively, one might argue that those with high
negative quality relationships are deeply engaged in family matters. These relations may have a protective effect
on the effects of sociopolitical stress. Negativity in close
social relations may overshadow stress from sociopolitical
events, thereby counterintuitively buffering the effect of
sociopolitical stress on psychological health. More directly, although again perhaps counterintuitively, the presence
of negativity (as measured by someone making too many
demands, getting on one’s nerves, attempting to control),
signifies social engagement, which is highly valued
among older Lebanese (Joseph, 1993). Moreover, the
stress by negative relationship quality interaction patterns
indicates that low negative quality relations links to high
depressive symptoms in the context of low stress. Such
findings may signify a type of disengagement. In other
words, the older adult is not connected at the interpersonal
or societal level – and hence experiences poor psychological health.
The convoy model of social relations guided the design
and analysis of this study. Analysis by age group allowed
for a preliminary investigation of life course patterns con-
25
cerning stress and psychological health. Moreover, we
had the advantage of testing how various dimensions of
social relations provide a resource depending on stresstype and age group. The opportunity to study effects of
sociopolitical stress on psychological health is quite novel. It signifies a macrolevel stressor that societal members
experience simultaneously. An entire society endures an
event during the same period. This stress experience differs from personal or individual level stress such as daily
hassles (e.g., noisy construction) or life events (e.g., death
of a loved one), which influence some but not all in a
society at any given point in time, the duration of which
varies from person to person. Extending the convoy model
to account for the stress-buffering role of social relations
in a specific country context provided a pioneering opportunity to study sociopolitical stress and the ways in which
social relations operate to influence psychological health.
This study suggests that quality of social relations emerge
as central in times of sociopolitical stress for middle-aged
and older participants, though age may shape the ways in
which positive and negative quality impinges on the
stress–well-being link.
Future Directions
Several avenues for future research are evident. Functional
approaches to the development of stability across the lifespan would be best examined with longitudinal panel data.
Though we presented aspects of stabilization by focusing
on the moderating role of social relations in the stress-psychological health link at different points in the life course,
having longitudinal data would render a more precise conclusion. Nonetheless, we approached our analysis by positioning social relations to function as a potential stabilizing
factor for psychological health in a specific sociopolitical
context. Though we had no means to examine age changes,
we did have the ability to document age-related differences. Despite the limitations, these findings do provide critical, preliminary evidence about stress, social relations, and
psychological health over the life course in an understudied
part of the world.
In sum, our findings show that sociopolitical stress takes
its toll on well-being differently by age. Overall, by focusing on a regionally representative sample of Lebanese at
different ages and at different points in the life course, this
study has provided a unique application of the convoy
model of social relations, specifying the complexity of social relations as a potentially stabilizing force. Advantages
of examining multiple dimensions of social relations are
showcased. Quality emerged as a critical aspect to understanding the stress experience, though the forms and extent
of its effect vary at different ages and depending on the
stress experienced. These findings indicate that the stabilizing potential of social relations is multifaceted, variable,
and context specific.
GeroPsych 26 (1) © 2013 Hogrefe Publishing
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26
K. J. Ajrouch et al.: Social Relations in Lebanon
Acknowledgments
This research was supported by grants from the Doha International Institute of Family Studies and Development
and the Lebanese National Council on Scientific Research. The authors of this research are fully responsible
for its content, which does not necessarily reflect views of
the funding sources.
Declaration of Conflicts of Interest
The authors declare that no conflicts of interest exist.
References
Abdurahim, S., Ajrouch, K. J., Jammal, A., & Antonucci, T. C.
(2012). Survey methods and aging research in an Arab sociocultural context: A case study from Beirut, Lebanon. Journal
of Gerontology: Social Sciences, 67, 775–782.
Abyad, A. (2001). Healthcare for older persons: A country profile
– Lebanon. Journal of the American Geriatrics Society, 49,
1366–1370.
Acierno, R., Ruggiero, K., Kilpatrick, D., Resnick, H., & Galea, S.
(2006). Risk and protective factors for psychopathology among
older versus younger adults after the 2004 Florida hurricanes.
American Journal of Geriatric Psychiatry, 14, 1051–1059.
Ajrouch, K. J., Antonucci, T. C., Akiyama, H., & Abdulrahim, S.
(2008, June). Older men and family relations in Lebanon: An
exploratory study. Presented at Global Trends and Challenges
Facing the Arab Family Lebanese American University-Byblos Campus, Beirut, Lebanon.
Antonucci, T. C. (1986). Measuring social support networks: Hierarchical mapping technique. Generations, 10(4), 10–12.
Antonucci, T. C. (2001). Social relations: An examination of social networks, social support and sense of control. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (5th ed., pp. 427–453). New York: Academic Press.
Antonucci, T. C., Ajrouch, K. J., & Janevic, M. R. (2003). The
significance of social relations with children to the SES-health
link in men and women aged 40 and over. Social Science and
Medicine, 56, 949–960.
Antonucci, T. C., Fuhrer, R., & Dartigues, J. F. (1997). Social relations and depressive symptomatology in a sample of community-dwelling French older adults. Psychology and Aging,
12, 189–195.
Antonucci, T. C., & Jackson, J. S. (1987). Social support, interpersonal efficacy and health. In L. L. Carstensen & B. A. Edelstein (Eds.), Handbook of clinical gerontology (pp. 291–311).
New York: Pergamon.
Barakat, H. (1976). Socioeconomic, cultural, and personality
forces determining development in Arab society. Social Praxis, 2, 179–204.
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000).
From social integration to health: Durkheim in the new millennium. Social Science and Medicine, 51, 843–857.
Berkman, L. F., & Syme, S. L. (1979). Social networks, host resistance, and mortality: A nine-year follow-up study of AlaGeroPsych 26 (1) © 2013 Hogrefe Publishing
meda county residents. American Journal of Epidemiology,
109, 186–204.
Birditt, K. S., Antonucci, T. C., & Tighe, L. (2012). Enacted support during stressful life events in middle and older adulthood:
An examination of the interpersonal context. Psychology and
Aging, 27, 728–741.
Birditt, K. S., & Fingerman, K. L. (2003). Age and gender differences in adults’ descriptions of emotional reactions to interpersonal problems. Journals of Gerontology: Psychological
Sciences, 58, P237–P245.
Carstensen, L. L., Isaacowitz, D. M., & Turk-Charles, S. (1999).
Taking time seriously: A theory of socioemotional selectivity.
American Psychologist, 54, 165–181.
Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied
multiple regression/correlations analysis for the behavioral
sciences. Mahwah, NJ: Erlbaum.
Cohen, S., & McKay, G. (1984). Social support, stress, and the
buffering hypothesis: A theoretical analysis. In A. Baum, S. E.
Taylor, & J. E. Singer (Eds.), Handbook of psychology and
health (pp. 253–267). Hillsdale, NJ: Erlbaum.
Cohen, S., & Syme, S. L. (1985). Social support and health. New
York: Academic Press.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and the
buffering hypothesis. Psychological Bulletin, 98, 310–357.
Connidis, I. A., & McMullin, J. A. (2002). Ambivalence, family
ties, and doing sociology. Journal of Marriage and Family,
64, 594–601.
Dannefer, D. (2003). Cumulative advantage/disadvantage and the
life course: Cross-fertilizing age and social science theory.
Journals of Gerontology, 58B, 327–337.
Dhabhar, F. S. (2009). Enhancing versus suppressive effects of
stress on immune function: Implications for immunoprotection
and immunopathology. Neuroimmunomodulation, 16,
300–317.
Durkheim, E. (1951). Suicide. New York: Free Press.
Elder, G. H. (1974). Children of the great depression: Social change
in life experience. Chicago: University of Chicago Press.
El Khoury, M., & Panizza, U. (2005). Social mobility and religion: Evidence from Lebanon. Research in the Social Scientific Study of Religion, 16, 133–160.
Farhood, L., Zurayk, H., Chata, M., Saadeh, F., Meshefedjian, G.,
& Sidano, T. (1993). The impact of war on the physical and
mental health of the family: The Lebanese experience. Social
Science and Medicine, 36, 1555–1567.
Fox, J. (1991). Regression diagnostics. Newbury Park, CA: Sage.
George, L. K., Blazer, D. G., Hughes, D. C., & Fowler, N. (1989).
Social support and the outcome of major depression. British
Journal of Psychiatry, 154, 478–485.
House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science, 241, 540–545.
Jaccard, J., & Turrisi, R. (2003). Interaction effects in multiple
regression. Thousand Oaks, CA, Sage.
Joseph, S. (1993). Connectivity and patriarchy among urban
working-class Arab families in Lebanon. Ethos, 21, 452–484.
Joseph, S. (2011). Political familism in Lebanon. The ANNLAS of
the Americans Academy of Political and Social Science, 636,
150–163.
Kahn, R. L., & Antonucci, T. C. (1980). Convoys over the life
course: Attachment, roles, and social support. In P. B. Baltes
& O. Brim (Eds.), Life-span development and behavior (Vol. 3,
pp. 253–268). New York: Academic Press.
Author's personal copy (e-offprint)
K. J. Ajrouch et al.: Social Relations in Lebanon
Kazarian, S. S., & Taher, D. (2010). Validation of the Arabic Center for Epidemiological Studies Depression (CES-D) scale in
a Lebanese community sample. European Journal of Psychological Assessment, 26, 68–73.
Khalaf, S. (1971). Family associations in Lebanon. Journal of
Comparative Family Studies, 2, 235–250.
Khalaf, S. (2001). Cultural resistance: Global encounters in the
Middle East. London: Saqi Books.
Larkin, C. (2010). Beyond the war? The Lebanese postmemory
experience. International Journal of Middle East Studies, 42,
615–635.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer.
Luescher, K., & Pillemer, K. (1998). Intergenerational ambivalence: A new approach to the study of parent-child relations in
later life. Journal of Marriage and the Family, 60, 413–425.
Mroczek, D. K., & Almeida, D. M. (2004). The effect of daily
stress, personality, and age on daily negative affect. Journal of
Personality, 72, 355–378.
Oxman, T. E., Berkman, L. F., Kasl, S., Freeman, D., & Barrett,
J. (1992). Social support and depressive symptoms in the elderly. American Journal of Epidemiology, 135, 356–368.
Pearlin, L. I. (2010). The life course and the stress process: Some
conceptual comparisons. Journal of Gerontology: Social Sciences, 65B, 207–215.
Radloff, L. S. (1977). The CES-D Scale: A self-report depression
scale for research in the general population. Applied Psychological Measurement, 1, 385–401.
Sabbah, I., Drouby, N., Sabbah, S., Retel-Rude, N., & Mercier,
M. (2003). Quality of Life in rural and urban populations in
Lebanon using SF-36 Health Survey. Health and Quality of
Life Outcomes, 1, 30.
Sabbah, I., Le Vuitton, D. A., Droubi, N., Sabbah, S., & Mercier,
M. (2007). Morbidity and associated factors in rural and urban
populations of South Lebanon: A cross-sectional communitybased study of self-reported health in 2000. Tropical Medicine
and International Health, 12, 907–919.
Sibai, A. M., Kanaan, M. N., Chaaya, M., & Campbell, O. M. R.
(2007). Mortality among married older adults in the suburbs
of Beirut: Estimates from offspring data. Bulletin World Health
Organization, 85, 482–486.
Sibai, A. M., Sen, K., Baydoun, M., & Saxena, P. (2004). Popu-
27
lation aging in Lebanon: Current status, future prospects and
implications of policy. World Health Organization Bulletin of
the World Health Organization, 82, 219–226.
Stewart, A. L., & Hays, R. D.(1997). Conceptual, measurement,
and analytical issues in assessing health status in older populations. In T. Hickey, M. A. Spears, & R. Prohaska (Eds.), Public health and aging (pp. 163–183). Baltimore, MD: Johns
Hopkins University Press.
Thoits, P. A. (1995). Stress, coping and social support processes:
Where are we? What next? Journal of Health and Social Behavior, 35, 53–79.
Thoits, P. A. (2010). Stress and health: Major findings and policy
implications. Journal of Health and Social Behavior,
51(Suppl.), S41–S53.
Umberson, D., & Montez, J. K. (2010). Social relationships and
health: A flashpoint for health policy. Journal of Health and
Social Behavior, 51(Suppl.), S54–S66.
Umberson, D., Williams, K., Powers, D. A., Liu, H., & Needham,
B. (2006). You make me sick: Marital quality and health over
the life course. Journal of Health and Social Behavior, 47,
1–16.
Windsor, T. D., & Anstey, K. J. (2010). Age differences in psychosocial predictors of positive and negative affect: A longitudinal investigation of young, midlife, and older adults. Psychology and Aging, 25, 641–652.
Yamout, R., & Jabbour, S. (2010). Complexities of research during war: Lessons from a survey conducted during the summer
2006 war in Lebanon. Public Health Ethics, 3, 293–300.
Manuscript submitted: 31.7.2012
Manuscript accepted after revision: 2.12.2012
Kristine J. Ajrouch
Department of Sociology, Anthropology, and Criminology
Eastern Michigan University
Ypsilanti, MI 48197
USA
[email protected]
GeroPsych 26 (1) © 2013 Hogrefe Publishing