APPLIED PSYCHOLOGY: HEALTH AND WELL-BEING, 2009, 1 (1), 2345 doi:10.1111/j.1758-0854.2009.01004.

Health and Subjective Well-Being in Later Adulthood: Different Health StatesDifferent Needs?
Benjamin Schz,* Susanne Wurm, Lisa M. Warner and Clemens Tesch-Rmer
German Centre of Gerontology, Berlin, Germany

From midlife on, health problems become more prevalent. Health is one of the key determinants of subjective well-being (SWB), but examining the relation between health and SWB in later adulthood is complicated by the clustering of multiple illnesses. This article proposes Latent Class Analysis (LCA) for a parsimonious description of adult health. This article compares SWB in health classes and examines the relative importance of socioeconomic resources, pain and coping (exible goal adjustment) for SWB. Data stem from a nation-wide representative sample of adults aged 4085 (German Ageing Survey, DEAS; N = 3,084). LCA was used to examine different congurations of health. Multiple regression analyses in latent classes were conducted to examine predictors of SWB. LCA generated four distinct classes of health conditions: No disease (n = 807), cardiovascular diseases (n = 405), joint problems (n = 1,612) and multiple illnesses (n = 258). As expected, only small mean differences in SWB indicators were found, whereas discontinuous predictors of SWB were detected: Coping was more strongly associated with SWB in individuals with higher illness burden. LCA can be applied to describe health in later adulthood. Differential prediction patterns suggest distinct factors for SWB depending on individual health status. Keywords: adult health, developmental psychology, Germany, health psychology, health status, latent class analysis, later adulthood, resource appraisal, subjective well-being

INTRODUCTION
The general increase in life expectancy is accompanied by a diversication of health. Some people stay relatively healthy up to old age, whereas others suffer from multiple illnesses already from midlife on (differential aging; Whitebourne, 2001). Nevertheless, only small differences in subjective well* Address for correspondence: Benjamin Schz, German Centre of Gerontology, Manfredvon-Richthofen-Str. 2, 12101 Berlin, Germany. Email: benjamin.schuez@dza.de 2009 The Authors. Journal compilation 2009 International Association of Applied Psychology. Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

24

SCHZ ET AL.

being emerge between age groups, at least for some dimensions (Kunzmann, Little, & Smith, 2000). However, the variability in individual health states can complicate the examination of the relation between health and subjective well-being. Additionally, illnesses tend to cluster with age (Laux, Kuehlein, Rosemann, & Szecsenyi, 2008). Therefore this paper aims at identifying health-related similarities and differences using latent class analysis. Moreover, the study examines whether subjective well-being differs according to health status and determines differential effects of socioeconomic and psychological resources for subjective well-being.

Health in Later Adulthood

Increasing age is often, but not normatively, associated with decreases in health status and increasing morbidity. It has been claimed that the co-occurrence of severe medical conditions is present in the majority of older adults (Fried, 2000). Large-scale studies underline this (e.g. van den Akker, Buntinx, Metsemakers, Roos, & Knotterus, 1998). They found that individuals in the age group between 20 and 39 years suffered on average from less than one illness, the group between 40 and 59 from around 1.3 illnesses, the group between 60 and 79 from 2.42 (male) and 2.61 (female) and the group over 80 from 3.24 (male) and 3.57 (female) illnesses. Such an accumulation of conditions has severe effects both on mortality (Schneeweiss, Wang, Avorn, & Glynn, 2003) and quality of life (Fortin et al., 2006). However, most studies so far have relied on examining the relation between morbidity and subjective well-being by either relating a morbidity count (weighted or unweighted; e.g. Tooth, Hockey, Byles, & Dobson, 2008) to SWB or on examining differences in individuals with or without the most common diseases in adulthood (Alonso et al., 2004). With increasing age, however, many people tend to suffer from more than one condition, which increases the complexity of the picture. For example, Laux et al. (2008) found typical age-related clustering of health problems in a large sample (N = 39,699), indicating that, for instance, the likelihood of developing diabetes type 2 increases tenfold in women with hypertension, and about eightfold in men with hypertension. It has thus been argued that the effects of multiple conditions consist of more than just the sum of single conditions (Fortin, Dubois, Hudon, Soubhi, & Almirall, 2007). However, so far only a small amount of work has been conducted to systematically examine the impact of differing, multiple conditions on SWB.

Analysing Multiple Illnesses: More than Just the Sum of Illnesses?

As outlined above, illnesses tend to cluster with age (Laux et al. 2008), implying differential effects on subjective well-being. However, the examination
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

25

of specic combinations of illnesses is associated with some complexity. One key problem involves the almost innite number of possible cells of combinations of any two or three illnesses.1 Such an examination strategy would inevitably face the problem of very small cell sizes or require very large samples. An additional difculty is posed by illnesses with shared symptoms, or rather asymptomatic conditions such as hypertension (Meyer, Leventhal, & Gutmann, 1985), and by shared effects of illnesses in terms of functional limitations. Here, it might be problematic for people to disentangle the effects of different illnesses on their subjective well-being. It might therefore be helpful to examine the phenomenon of multiple illnesses in an accumulative way, i.e. by grouping illnesses (Deeg, Portrait, & Lindeboom, 2002). Such a procedure would also suggest that the accumulation of conditions results in qualitatively different health states. This grouping can be organised according to the organ system which has been affected most (Charlson, Szatrowski, Peterson, & Gold, 1994), according to similar medical aetiologies (Kriegsman, Deeg, & Stalman, 2004), or, relying on epidemiological data (i.e. on empirical co-occurrences), on conditions frequently being present in combination (Deeg et al., 2002; Portrait, Lindeboom, & Deeg, 2001). While the rst two approaches represent top-down classications along predened combination rules, the latter one is a bottom-up approach that relies solely on empirical health indicators. This paper uses a bottom-up approach to examine the effects of multiple illnesses on subjective well-being and to determine whether there are differential resources for SWB according to health status. It has to be noted that the procedure of conjoining individual information in groups is accompanied by a reduction in the information available from the indicators (Agresti, 2002), thus being similar to factor analysis. This reduction of information, however, needs to be justied through practical implications. This would be the case if individuals in different latent classes of health and illness relied on different resources for subjective well-being, which would suggest differential psychosocial interventions. Hence, the question is whether the identication of latent classes offers more distinct information than the arrangement of the classes on an underlying continuum, for example illness burden. A procedure of testing such qualitative differences between distinct categories as compared to an assumed underlying continuum has been proposed by Weinstein, Rothman, and Sutton (1998) in the context of stage theories of health behaviour. One key criterion of qualitative differences is the identication of discontinuous
1 For example, using the popular Charlson Comorbidity Index assessing 19 different conditions, (19 * (19 - 1))/2 = 171 cells would be needed to examine all possible non-redundant combinations of two, and (19!/(6*16!)) = 969 cells for all possible non-redundant combinations of three illnesses.

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

26

SCHZ ET AL.

patterns between the categories if aligned on a hypothetical underlying continuum in terms of means or regression weights in multigroup models.

Subjective Well-Being and its Correlates in Later Adulthood

Subjective well-being is usually considered as consisting of cognitive and emotional components (E. Diener, Kesebir, & Lucas, 2008). The cognitive component describes the outcomes of subjective evaluations of concurrent or general states, whereas the affective component describes both state-like affective reactions to circumstances and relatively stable affective dispositions. The present paper considers both components of subjective well-being. Health is one of the key determinants of subjective well-being (E. Diener et al., 2008), affecting subjective well-being both directly and indirectly (e.g. mediated by functional limitations). However, it has been discussed that the impact of severe health conditions is transitory, with levels of subjective well-being returning to initial levels (or levels close to the initial levels) after some time (Frederick & Loewenstein, 1999). Thus, a cross-sectional perspective on health and well-being should reveal only small differences between individuals with different health states. As the objective and subjective resource status of individuals varies with their health status, however, it has been suggested that although mean levels of subjective well-being might be similar, the individual resources and evaluations underlying these similar levels can differ (Schwartz et al., 2006). A plethora of factors that affect subjective well-being have been discussed. Here, we concentrate on three central correlates of subjective well-being in later life: rst, the effects of individuals appraisals of their economic and social situation, second, the impact of pain due to illness, and nally, the effects of coping with adversity, namely the ability to adjust personal goals to the individual resource status (exible goal adjustment; Brandtstdter & Rothermund, 1994).

Socioeconomic Situation and Subjective Well-Being

The individual social and economic situation constitutes an important resource for subjective well-being (Biswas-Diener, 2008). Several pathways and mediators have been suggested. For example, material wealth could contribute to experiences of relative autonomy and progress towards personally relevant goals (E. Diener et al., 2008). Additionally, the fullment of basic needs of everyday living and having sufcient access to necessary resources should contribute to subjective well-being (Maslow, 1954). However, in terms of this basic needs theory, the relative importance of individuals appraisals of their material wealth for subjective well-being
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

27

should depend on their life circumstances: for example, in individuals with strong health-related limitations, appraisals of the economic situation should be less important for subjective well-being than more proximal predictors such as their social situation or coping styles. Rather than objective measures of resources, however, subjective evaluations of domains have been shown to predict subjective well-being (Smith, Fleeson, Geiselmann, Settersten, & Kunzmann, 1999). Similarly, being embedded in a satisfying and rich social network has been shown to be an important prerequisite for subjective well-being (E. Diener & Seligman, 2002; M.L. Diener, Diener McGavran, Eid, & Larsen, 2008). Apart from this generic effect, it has been suggested that emotionally supportive relations such as friendships are increasingly important with decreasing time perspective due to age or illness (Carstensen, 1995; Lckenhoff & Carstensen, 2004). Thus, such resources should be more important for subjective well-being with increasing illness burden. In particular, self-selected resources such as friendship compared to family is assumed to provide emotional support; thus friendship appraisals might be differentially affecting subjective well-being compared to family support.

Pain and Subjective Well-Being

Pain related to an illness has a strong impact on subjective well-being, both directly (Niv & Kreitler, 2001) and indirectly, mediated by reduced mastery of everyday life (Windle & Woods, 2004). However, the effects of pain on subjective well-being might be more strongly pronounced in otherwise relatively healthy individuals compared to individuals with multiple conditions, where other factors can have stronger relative impact on subjective well-being (Schwartz et al., 2006).

Coping: Flexible Goal Adjustment

Flexible goal adjustment describes the individual ability to rescale personal goals and strivings to available resources and thus cope with diminishing resources. The concept is part of a dual framework of goal attainment with an assimilative and an accommodative pathway (Brandtstdter & Rothermund, 2002). Accommodative activities are related to rescaling desired outcomes in order to adjust them to available resources. In terms of life-course dynamics, it has been proposed that in the face of potential losses and health threats in older age, accommodative tendencies such as exible goal adjustment become more important for maintaining subjective well-being than strategies to tenaciously adhere to desired but unaccomplishable goals. The accommodative process of rescaling or adjusting personal goals according to available resources predicts higher subjective well-being in general (Wrosch, Scheier,
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

28

SCHZ ET AL.

Miller, Schulz, & Carver, 2003) and in the face of age-related developmental losses (Brandtstdter & Renner, 1990).

Research Questions
The main research aims of this study therefore are threefold: rst, to determine whether the health status of older individuals can be grouped into homogeneous subpopulations according to multidimensional indicators of health using latent class analysis; second, whether these subpopulations differ with regard to their subjective well-being; and third, whether the resources for subjective well-being differ between these subpopulations. H1: Latent Class Analysis for Health Indicators. We expect qualitatively different latent classes of health in later adulthood. The qualitative differences are evaluated using suggestions for detecting qualitative differences between categories (Weinstein et al., 1998). H2: Subjective Well-Being. With regard to subjective well-being, we expect little differences between the classes on all indicators of subjective well-being because, as outlined above, individuals often adapt to chronic illnesses. However, individuals with many illnesses should score lower on SWB indicators than relatively healthy individuals. H3: Resources for Subjective Well-Being. Here, we hypothesise that individuals appraisals of emotional resources (friends and family) should be more strongly attenuated in individuals with limited time perspective (due to age and/or illness burden), whereas individuals appraisals of tangible resources (economic situation) should be more important in individuals with extended time perspective (younger and/or fewer illnesses; Lckenhoff & Carstensen, 2004). With regard to accommodative coping strategies in terms of rescaling goals in accordance to the current situation (Brandtstdter & Renner, 1990; Brandtstdter & Rothermund, 2002), we hypothesise that individuals in classes with signicant health-related losses, in particular, will show stronger associations between accommodative coping and satisfaction with life.

METHOD

Participants and Procedure

All analyses are based on data from the second wave of the German Ageing Survey (DEAS) conducted in 2002. DEAS is a nation-wide and populationbased survey of the adult population between the ages of 40 and 85 (Engstler
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

29

& Wurm, 2006) and is funded by the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth.2 The sample for this study was drawn by a national probability sampling stratied by age, sex, and place of residence (Eastern, i.e. former GDR or Western Germany). The study comprised a standardised interview and an additional questionnaire.

Measures
Health Status. Health is a multidimensional construct, consisting of several psychosocial facets (World Health Organization, 1946). For the purpose of this study, we concentrated on physical and psychological components of health, with the physical component decomposed into functional status and a disease list, and the psychological component assessed via depressive symptomatology and cognitive capacity. The LCA therefore was based on 14 indicators, namely a list of 11 diseases, a measure of physical functioning and two indicators of psychological health, depressive symptoms, and cognitive capacity. The disease list consisted of 11 conditions (e.g. cardiovascular diseases, diabetes, cancer, respiratory diseases, eye diseases, hearing problems) and was presented to participants in the questionnaire. It was informed by the disease list for the Charlson Comorbidity Index (Charlson et al., 1994), which is widely used to determine the occurrence of comorbid conditions. The physical functioning subscale of the short-form health survey SF-36 (Ware & Sherbourne, 1992) was used to indicate functional status (above/below median). Depressive symptoms were assessed by the Centre for Epidemiological Studies-Depression scale (CES-D; Radloff, 1977). For the purpose of this study, we dichotomised the scale at the 15-item short-version adjusted clinical cut-off point for the German norm population of one standard deviation above the mean (Hautzinger & Bailer, 1993). Cognitive capacity was assessed via the digit-symbol test (D-S-T) from the Wechsler Adult Intelligence Scalerevised (WAIS-R; Wechsler, 1981). Age-adjusted cut-off scores for an average intelligence score were derived from Sattler (1982) and the individual digit-symbol scores were dichotomised into 0 (below average) and 1 (average and above). Subjective Well-Being and Predictors. Satisfaction with life was assessed in the questionnaire using the satisfaction with life scale (SWLS; E. Diener, Emmons, Larsen, & Grifn, 1985). The SWLS consists of ve items with a 5-point response format. It has been used in numerous studies (for an
2 All instruments and sample descriptions (in German) are available online (www.germanageing-survey.org).

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

30

SCHZ ET AL.

overview, see e.g. Pavot & Diener, 1993) and forms a reliable and changesensitive indicator of general satisfaction with life. Positive and negative affect were assessed in the questionnaire using the PANAS scale consisting of 20 items (10 items positive, 10 items negative affect; Watson, Clark, & Tellegen, 1988). Individuals were asked to indicate how often in the last month they experienced a range of affects (e.g. enthusiastic for positive or hostile for negative affect) on a scale ranging from 1 (never) to 5 (very often). Pain was assessed in the interview using a single item: To what extent do you feel that physical pain prevents you from doing what you need to do? based on the WHOQoL-BREF questionnaire (World Health Organization, 1993). Participants answered this item on a scale ranging from 1 (not at all) to 5 (an extreme amount). Individual appraisals of family, friends, and the economic situation were assessed with three single items in the interview: On an overall level, how would you rate . . . (a) . . . your relation to your family, (b) . . . your relation to your friends, (c) . . . your economic situation? Answers were given on 5-point scales from 1 (very bad) to 5 (very good). Flexible goal adjustment was assessed in the questionnaire using the 10-item scale as reported by Freund and Baltes (2002). The items are to be answered on a 5-point Likert scale from 1 (not at all true) to 5 (totally true). An example item is, Even if everything goes wrong, I still can nd something positive about the situation.

Analytical Procedure
In order to summarise the information obtained by the health status indicators, we conducted Latent Class Analyses (LCA) using Mplus Version 5.0 (Muthn & Muthn, 2007). Missing data (less than 10% on any of the indicator variables) were imputed using the Full Information Maximum Likelihood method (FIML). Similar to factor analysis, LCA aims at nding a reduced set of dimensions that explains the relations between the variables. Unlike factor analysis, LCA assumes that the latent variable is categorical, and indicators can be nominal. The number of latent classes in LCA can be obtained by comparing t indices of solutions with varying numbers of classes. Fit indices for LCA are the likelihood ratio c2 statistic, the Akaike Information Criterion (AIC) and the Bayesian information criterion (BIC). Because the likelihood ratio c2 statistic is sample-size dependent, it tends to be less informative the larger the sample size gets. Additionally, the Lo-MendellRubin adjusted likelihood ratio test (Lo, Mendell, & Rubin, 2001) was used to determine the number of latent classes in the model, because it allows one to compare models with differing numbers of latent classes, with
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

31

non-signicant values (p < .05) indicating that the model with k - 1 classes should be accepted. ANOVAs between classes were conducted to compare age, number of illnesses, appraisals of life standard, family and friends, satisfaction with life, positive and negative affect, and exible goal adjustment. Post-hoc tests (Tukey HSD or Tamhane T2) were performed according to the assumption of equality of variances between groups. Finally, satisfaction with life and positive as well as negative affect were regressed on the predictors while controlling for the stratication factors age, gender, and region of residence. Regression analyses were performed separately in each latent class in order to examine differential resource patterns. Regression coefcients were compared with regard to the 95 per cent condence interval for the unstandardised regression coefcients, adjusted for multiple comparisons.

RESULTS

Characteristics of Study Sample

Of the 3,084 participants who took part in the study, 2,787 (90.4%) answered both the interview questions and the questionnaire, whereas 297 (9.6%) did not ll in the questionnaire. These participants had to be dropped from all analyses, because several variables were assessed in the questionnaire. Logistic regression analysis was used to examine differences between participants and non-participants in the questionnaire by predicting participation with all variables that were available from the interview. Participants with higher appraisals of their living standard (OR = 1.34, p < .05) were signicantly more likely to partake in the questionnaire, whereas participants with higher depressive symptomatology were more likely to refuse the questionnaire (OR = .91, p < .01); all other predictors did not reach signicance. Participants were aged between 40 and 85 years (M = 61.38). About half of the participants were female (49.8%), about 67.2 per cent of participants lived in former Western Germany, and 32.8 per cent lived in former Eastern Germany. The high proportion of older adults and people living in Eastern Germany is due to sample stratication. Age, gender, and place of residence are therefore treated as control variables in the following analyses. Table 1 sets out other characteristics of the study sample and the intercorrelations of the study variables.

Latent Class Analyses

The results of the Latent Class Analyses suggest that a model with four latent classes ts the data better than the three- or ve-class solutions (see Table 2),
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

32

SCHZ ET AL.

TABLE 1 Sample Characteristics (N = 3,084) and Intercorrelations

2. .34*** -.37*** -.31*** .22*** -.14*** .11*** -.40*** .21*** -.08*** .31*** -.63*** .48*** -.18*** .36*** .06** .15*** -.09*** .07** -.25*** -.15*** .05** .04** -.06** .03 -.15*** -.08** .19*** .26*** -.08** .12*** -.05** .08*** -.18*** -.09*** .18*** .05** .06** -.06** .03 -.23*** -.09*** .14*** .17*** .13*** 3. 4. 5. 6. 7. 8. 9. 10. 11. .05** .22*** -.21*** .05** -.40*** -.24*** .45*** .23*** .23*** .40*** 12. -.21** .32*** -.21*** .17** -.36*** -.29*** .27*** .24*** .16*** .39*** .48*** 13. -.14** -.10*** .22*** .04 .42*** .19*** -.19*** -.08** -.08** -.29*** -.36*** -.21***

Variable

Mean

SD

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Age Physical functioning Number of illnesses Digit-Symbol-Score CES-D Sum Score Pain Appraisal economy Appraisal friends Appraisal family Flexible goal adjustment Satisfaction with life Positive affect Negative affect

61.38 82.18 2.05 45.08 8.09 1.79 3.73 4.10 4.03 2.40 3.81 3.44 1.98

12.59 25.08 1.92 19.32 5.08 1.00 .72 .66 .77 .50 .80 .61 .57

-.45***

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

Note: *** p < .001; ** p < .01; *p < .05.

HEALTH AND SUBJECTIVE WELL-BEING TABLE 2 Results from Latent Class Analyses
% Reduction in L2 0 14.28 21.71 26.31 28.04

33

Model One-class Two-class Three-class Four-class Five-class

AIC 34983.83 32863.60 32569.35 32466.83 32429.03

BIC 35068.30 33038.57 32835.11 32922.79 32875.49

L2 2821.27 2446.73 2209.82 2079.96 2030.27

df 16163 16240 16229 16211 16198

Lo-Mendell-Rubin Test for k-1 classes / 2132.53*** 321.29** 131.73* 67.24 ns

Note: *** p < .001; ** p < .01; * p < .05.

FIGURE 1. Item prole for 4-class solution: Relative prevalence of conditions in classes. Note: D-S-T: Digit-Symbol-Test scores with age-adjusted cut-off scores for above/below average; low PF: SF-36 physical functioning subscale below median; CES-D: Centre for Epidemiological Studies-Depression scale with clinical cut-off score.

because the Lo-Mendell-Rubin test for the ve-class solution was not signicant, suggesting that we accept the solution with k - 1 classes. Class order was rearranged in order to reect increasing illness burden from class 1 to 4. The four latent classes differ with regard to the probability of the prevalence of different health conditions (Figure 1). Individuals whose most likely
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

34

SCHZ ET AL.

class membership is in latent class 1 (n = 807) have low incidence probabilities for all illnesses and have the highest probabilities for being above the median of the SF-36 physical functioning subscore and the Digit-Symbol-Test score. Latent class 2 (n = 1,612) is characterised by moderate incidence probabilities for all illnesses, but has a high likelihood of joint problems. Latent class 3 (n = 405) is characterised by the highest incidence rates of cardiovascular problems and the highest probability of scoring below the median on the SF-36 PF subscale, indicating low functional status. Additionally, individuals in this class have the highest probability of suffering from diabetes. Latent class 4 (n = 258) is characterised by the highest relative incidence rates for all illnesses except diabetes and cardiovascular diseases, and has the highest probabilities of sight as well as hearing problems, and of scoring below the median on the SF-36 physical functioning subscale. Mean differences between individuals according to their most likely class membership are depicted in Table 3. We will only point to some noteworthy ndings: individuals in latent classes 3 and 4 are not signicantly different with regard to age, but individuals in latent class 4 report signicantly more illnesses (5.99) than those in latent class 3 (3.8). All classes differed signicantly with regard to pain, with class 1 reporting the lowest levels and class 4 reporting the highest levels of limitations due to pain. The other predictors were mainly similar between classes, with low mean differences. In terms of indicators of subjective well-being, individuals in latent class 1 scored highest on indicators of well-being (life satisfaction and positive affect) and individuals in latent class 4 scored highest on negative affect. The highest mean differences between the latent classes are around half a scale point

TABLE 3 Means of Study Variables According to Most Likely Class Membership

Variable Age1 Number of illnesses1 Pain1 Appraisal economy1 Appraisal friends1 Appraisal family1 Flexible goal adjustment2 Satisfaction with life1 Positive affect1 Negative affect1 Latent Class 1 (n = 807) 54.05a .29a 1.10a 3.85a 4.17a 4.09a 2.37a 4.02a 3.66a 1.83a Latent Class 2 (n = 1,612) 61.75b 1.87b 1.77b 3.73a 4.10a,b 4.02a,b 2.39a,b 3.84b 3.46b 1.98b
1

Latent Class 3 (n = 405) 69.68c 3.8c 2.43c 3.56b 4.03a,b 3.99a,b 2.45a,b 3.50c 3.11c 2.10c

Latent Class 4 (n = 258) 68.86b 5.99d 2.74d 3.59b 4.00b 3.91b 2.47b 3.54c 3.28d 2.28d
2

Note: Means with different subscripts differ at p < .05, based on HSD post-hoc tests.

Tamhane T2 post-hoc tests or

Tukey

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

35

(.52 for satisfaction with life between classes 1 and 3, .55 for positive affect between classes 1 and 3, and .45 for negative affect between classes 1 and 4), and the mean levels are above the theoretical mean of the scale (3), indicating relatively high subjective well-being.

Predicting Subjective Well-Being

In a series of multiple regression analyses, satisfaction with life, positive and negative affect were regressed on age, sex, region of residence, pain, individual appraisals of living standard, family and friends, as well as exible goal adjustment for the four latent classes separately (see Table 4). The prediction patterns of the different indicators of subjective well-being suggest differential impact of pain, subjective appraisals of economic situation, friends and family on subjective well-being in the latent classes. Regarding satisfaction with life, the appraisal of friends predicted satisfaction with life only in classes 2 (b = .08, p < .01) and 4 (b = .25, p < .001), and these regression coefcients were signicantly different from those in the other classes. Flexible goal adjustment predicted satisfaction with life signicantly better in classes 3 (b = .45, p < .001) and 4 (b = .39, p < .001) than in classes 1 (b = .25, p < .001) and 2 (b = .29, p < .001). This differential prediction pattern supports qualitative differences between both latent classes 2 and 3 as well as latent classes 3 and 4. Individuals in all classes proted from higher appraisal of their economic situation and positive appraisals of their family relations. With regard to positive affect, the appraisal of the economic situation signicantly predicted positive affect in individuals in classes 1, 2, and 3, with the non-signicant predictor in class 4 (b = .05, ns) being signicantly lower than the coefcient in class 1 (b = .24, p < .001). The prediction pattern of exible goal adjustment closely matches that of the prediction of satisfaction with life, with the predictor being signicantly stronger in classes 3 (b = .44, p < .001) and 4 (b = .47, p < .001) than in class 1 (b = .34, p < .001). With regard to the prediction of negative affect, pain signicantly predicted negative affect in classes 1 (b = .15, p < .001) and 2 (b = .10, p < .001), with the regression coefcient in class 4 being signicantly lower than in class 1. Appraisal of the relation to friends was only predictive of negative affect (inversely related) in class 4 (b = -.28, p < .001), with this regression coefcient being signicantly higher than all others.

DISCUSSION
The main research aims of this study were to examine congurations of health indicators in older individuals, their impact on life satisfaction, and the degree to which pain, subjective appraisals of individuals social as well as
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

36
SCHZ ET AL.

TABLE 4 Summary of Multiple Regression Analyses of Subjective Well-Being Indicators on Personal Resources for Members of the Latent Classes 14, Controlled for Stratication (Age, Gender, Region of Residence)
Latent Class 3 (n = 1,612) Joint Diseases B SEB b B SEB b B Latent Class 2 (n = 405) Cardiovascular Diseases Latent Class 4 (n = 258) Multiple Illnesses SEB b

Latent Class 1 (n = 807) No Illnesses SEB b

Indicator

Predictor

Satisfaction with life Pain Appraisal economy Appraisal friends Appraisal family Flexible goal adjustment .06 .03 .04 .03 .05 -.04 .40*** .04 .11*** .25*** .02 .02 .03 .02 .04 .04 .06 .06 .05 .08 -.09 .37 .09b .06 .44a -.11*** .36*** .08** .06** .29*** -.09 .29 .02a .16 .77b .39*** .32*** .37***

-.08 .41 .04a .11 .37a

-.11* .23*** .02 .15** .45***

-.10 .26 .26b .05 .66b

.04 .07 .06 .06 .09

-.13** .21*** .25*** .06 .39***

R2adj.

.35***

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology. .05 .04 .03 .03 -.07 .24*** .13*** .04 .02 .02 .02 .02 -.08 .15a,b .09 .07 -.12*** .19*** .10*** .09*** -.07 .18a,b .04 -.03 .03 .05 .05 .04 -.11* .19*** .05 -.04 -.09 .04b .14 .00 .03 .05 .04 .04 -.17** .05 .19** .00

Positive affect Pain Appraisal economy Appraisal friends Appraisal family

-.10 .19a .12 .03

TABLE 4 Continued
Latent Class 3 (n = 1,612) B SEB b B SEB B b Latent Class 2 (n = 405) Latent Class 4 (n = 258) SEB b

Latent Class 1 (n = 807) SEB b

Indicator

Predictor

Positive affect Flexible goal adjustment .04 .34*** .38a,b .03 .56b .06 .33*** .44*** .24*** .24*** .28***

.38a

.54b

.06

.47***

R2adj.

.34***

Negative affect Pain Appraisal economy Appraisal friends Appraisal family Flexible goal adjustment .05 .03 .03 .03 .04 .15*** -.16*** .01 -.01 -.23*** .06a,b -.02 -.01a -.00 -.28 .02 .02 .02 .02 .03 .05a,b -.09 -.01a -.02 -.27 .10*** -.03 -.01 -.00 -.24*** .16*** .14***

.21a -.11 .01a -.01 -.23

.03 .05 .05 .04 .06

.09 -.10* -.01 -.03 -.22***

.02b -.07 -.21b .10 .29

.03 .05 .05 .04 .07

.04 -.08 -.28*** .14** -.24***

R2adj.

.23***

.25***

HEALTH AND SUBJECTIVE WELL-BEING

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

Note: * p < .05; ** p < .01; *** p < .001. SEB.: Standard error of regression weight. Unstandardised regression weights (B) printed in bold bearing different subscripts differ at p < .05 between latent classes based on post-hoc tests.

37

38

SCHZ ET AL.

economic situation, and the ability to exibly adjust personal goals differentially predicted different aspects of subjective well-being. This study adds to the existing literature by suggesting qualitatively different groups of health status and by providing evidence for the differential effects of personal resources on SWB depending on individual health status.

Health Status and Subjective Well-Being (H1 and H2)

LCA identied four latent classes of individuals according to their conguration on several health indicators. As with all classication approaches, a reduction of information compared to the information available from the original indicators occurs. In contrast to predened grouping criteria as in classications according to shared risk factors or affected organ systems (top-down approaches), we employed an epidemiology based (bottom-up) approach by identifying congurations of health indicators according to their frequency of co-occurrence. For the examination of the relation between health status and SWB, this approach might have advantages over the other approaches. A bottom-up approach as employed here allows us to examine this relation without the need for a full examination of all combinations of single conditions, which would result in a very large number of possible cells. We aimed at a multidimensional operationalisation of health (World Health Organization, 1946), incorporating indicators of functional and psychological health along with a disease list. While such a multidimensional approach might be criticised for mixing up differential aspects of health, we explicitly aimed at including functional and psychological indicators of health to account for differential subjective experiences with multiple illnesses, thus accounting for the notion that multimorbidity might be more than just the sum of illnesses (Fortin et al., 2006, 2007). With regard to the validity of the latent classes, it has to be ensured that the distinction between classes offers more information than arranging individuals on an underlying continuum of illness burden. Table 3 suggests that the mean differences follow a linear pattern, and post-hoc trend analyses revealed strong signicant linear trends for all variables. However, the examination of the prediction patterns of SWB reveals discontinuity between the classes: while exible goal adjustment and economic appraisal could be aligned on a linear continuum, both pain and the appraisal of friendship relation follow a sequence different from what an underlying continuum would suggest (see Table 4). This nding suggests qualitative differences between the classes (Weinstein et al., 1998). The four classes identied here approximately correspond to those identied in other studies (Deeg et al., 2002; Portrait, Lindeboom, & Deeg, 1999). It is notable that there is a substantial proportion of individuals (latent class
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

39

1, n = 807; 26.2%) who enjoy good health with high functional status. This class also enjoyed signicantly higher levels of satisfaction with life than the other classes. However, a substantial proportion of individuals (latent class 4, n = 258; 23.11%) suffer from multiple conditions, especially cardiovascular diseases and joint problems; moreover, they have a high prevalence of respiratory, gastric, diabetes, and gall bladder problems. Accordingly, functional limitations were most prominent among individuals in class 4. With regard to life satisfaction, however, individuals in this class scored similarly to those in latent class 3, with mainly cardiovascular diseases. This is consistent with previous studies which found fatal or fatally perceived diagnoses to be associated with low satisfaction with life. The mean differences between the classes might seem small, with the greatest difference spanning over roughly half a scale point (Table 3). However, such relatively small mean differences in subjective well-being do in fact reect substantial differences (Lucas, 2007). A substantial proportion of individuals is affected by cardiovascular diseases (latent class 2, 13.1%). This class also shows the highest incidence of diabetes, which suggests that the diseases of individuals in these classes might be lifestyle-related (Taylor, 2008). The largest proportion of individuals (52.3%) had their most likely class membership in class 2, which is characterised by relatively high incidence probabilities for joint problems and moderate to low incidence rates for other diseases. This pattern points to age-degenerative symptoms, which is also underlined by the nding that individuals in latent class 2 were signicantly older than those in the healthy class 1, but also signicantly younger than those in the other two classes. In terms of life satisfaction, individuals in latent class 2 scored lower than those in latent class 1, but higher than the individuals in the other classes. Longitudinal studies might be able to examine possible class transitions between the classes and the question of which variables would determine such a transition pattern or deviations.

Predicting Subjective Well-Being (H3)

This article operationalised subjective well-being with the facets satisfaction with life, positive affect, and negative affect. The intercorrelations of these facets (Table 1) suggest that these facets tap into related, albeit substantially distinct, aspects of subjective well-being. In terms of predictors of subjective well-being, there were no signicant differences between the groups with regard to the appraisal of family relations, which yielded comparably small coefcients for all aspects of subjective well-being. Although there are studies which suggest the important role of family relations for subjective well-being (for an overview, see M.L. Diener et al., 2008), our ndings suggest that subjective appraisal of friendship might
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

40

SCHZ ET AL.

be a more important predictor of subjective well-being, especially in individuals with limited time perspective due to higher age or higher illness burden (Lckenhoff & Carstensen, 2004). The other predictors (pain, economic appraisal, friendship appraisal, exible goal adjustment) were differentially predictive of subjective well-being according to classes: the importance of pain for subjective well-being is especially pronounced in the facet of negative affect. Here, pain was predictive in latent classes 1 and 2, but not in classes 3 and 4. Furthermore, the coefcients between classes 1 and 4 were signicantly different. This points to the notion that although individuals in classes 3 and 4 experienced higher levels of limitations due to pain than the other classes, this aspect might be inferior for their construction of negative affect, possibly due to habituation effects or response shifts for the construction of subjective well-being. The appraisal of the individuals economic situation showed indifferent prediction patterns in terms of satisfaction with life and negative affect. This points to the importance of being satised with ones economic situation for subjective well-being, which is not surprising, given that this has been a fundamental tenet of social psychology since basic needs theory was propounded (Maslow, 1954). However, in terms of positive affect, there were signicant differences between the classes, with the economic appraisal being a signicant predictor in individuals in latent classes 1, 2, and 3, but not for individuals in latent class 4 (b = .05, ns). This nding is noteworthy, as our hypotheses would predict that in classes with limited time perspective (3 and 4), such tangible resources would be less important. However, individuals in class 3 proted from higher appraisals of their economic situation, which points to qualitative differences between classes 3 and 4. Here, we can only speculate that in terms of time perspective, individuals with mainly cardiovascular diseases perceive these as more controllable and thus base their subjective well-being more on tangible resources (Lckenhoff & Carstensen, 2004). There were also differential prediction patterns for satisfaction with life with regard to the appraisal of friendship, with individuals in classes 2 and 4 proting more from positive appraisals of friendship than individuals in the other two classes. While the importance of emotional resources such as friendship support (rather than family support alone) for individuals with limited time perspective has been well documented (Carstensen, 1995), we can only speculate about the importance of friendship appraisal in individuals in class 2 (mainly joint problems). It may be possible that in individuals in this class, age-related decline symptoms such as joint problems signal beginning health problems, which might trigger rst notions of limitations in their time perspective rather than in individuals in class 3, which has manifest health problems, but who might on the other hand have adapted to their relatively controllable problems of cardiovascular diseases in terms of an extending
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

41

time perspective. Individuals in class 4 are challenged by an especially frail health status and limited time perspective, thus preferring emotional resources over tangible ones (Lckenhoff & Carstensen, 2004). In terms of negative affect, friendship appraisal constituted a protective factor only in individuals in class 4, which points to the idea that social support is especially benecial in individuals with high illness burden (Cohen & Wills, 1985). Flexible goal adjustment was more strongly associated with subjective well-being in individuals with high illness burden (classes 3 and 4), both for positive affect and satisfaction with life. This is consistent with the dual framework of development (Brandtstdter & Rothermund, 2002), which suggests that accommodative processes of reframing unrealistic goals whenever resources are low is benecial for subjective well-being. Theory suggests that this might work in two waysfreeing of resources otherwise bound by untenable goals, and preventing setbacks due to goal non-attainment. The nding that this resource is signicantly more important for subjective well-being in relatively ill individuals also points to the idea of differential intervention contents. In addition to the development-related argumentation in the original theory, our ndings suggest that health status might be an important mediator in explaining age-related effects of exible goal adjustment.

Limitations and Suggestions for Further Research

This study has some limitations which need to be noted. First, it is based on a cross-sectional data set, which neither allows causal inferences nor offers change perspectives. Clearly, replication of the current ndings and research on the transitions between classes in a longitudinal setting are called for. However, the data set is based on a representative sample of the German adult population aged 40 and older, which allows for some generalisability of the ndings. A second limitation is that all illnesses were self-reported, and no objective verication between diagnoses was available. Comparative studies suggest high consistencies between self-reported and record-based condition lists (Chaudhry, Jin, & Meltzer, 2005), which speaks in favour of the usability of self-reported data. Nevertheless, it would be fruitful to examine the validity of health status classes with objectively measured health data. Third, the LCA is based on binary indicators, which is associated with information loss for the scales that have been categorised (WAIS, CES-D, and SF-36). However, we used evidence-based and age-adjusted cut-off scores whenever available (Hautzinger & Bailer, 1993; Sattler, 1982). Finally, subjective appraisals and subjective well-being might share conceptual overlap, with individuals high in subjective well-being also appraising their subjective situation more positively. However, both causal directions are possible, and we chose to employ subjective assessments of the social and
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

42

SCHZ ET AL.

economic situation in order to avoid the problem of individual set-points and relative standards in the individual evaluation of material and social resource status (Biswas-Diener, 2008).

Implications
Despite these limitations, we think this study has some practically relevant implications. Our ndings suggest that describing adult health status with a limited set of dimensions might be a viable and parsimonious alternative to mere illness counts. Qualitative differences between latent classes of health were supported by discontinuous prediction patterns for subjective wellbeing. These class-specic prediction patterns also suggest that examining the effects of differential interventions targeting, e.g. mobilisation of social support in individuals with beginning age-degenerative problems as well as multimorbid individuals and self-regulation in terms of rescaling unrealistic goals in individuals with high illness burden (Wrosch et al., 2003) might be benecial for subjective well-being.

ACKNOWLEDGEMENTS
The data used in this article are from the German Ageing Survey (DEAS), available via www.ageing-survey.org. The German Ageing Survey is funded by the German Federal Ministry for Family Affairs, Senior Citizens, Women and Youth, Grant 301-1720-2/2. The rst and third authors are funded by the German Federal Ministry of Education and Research, Grant 01ET0702.

REFERENCES
Agresti, A. (2002). Categorical data analysis (2nd edn.). New York: Wiley. Alonso, J., Ferrer, M., Gandek, B., Ware, J.E., Jr., Aaronson, N.K., Mosconi, P. et al. (2004). Health-related quality of life associated with chronic conditions in eight countries: Results from the International Quality of Life Assessment (IQOLA) Project. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation, 13(2), 283298. Biswas-Diener, R.M. (2008). Material health and subjective well-being. In M. Eid & R.J. Larsen (Eds.), The science of subjective well-being (pp. 307322). New York; London: Guilford. Brandtstdter, J., & Renner, G. (1990). Tenacious goal pursuit and exible goal adjustment: Explication and age-related analysis of assimilative and accommodative strategies of coping. Psychology and Aging, 5(1), 5867. Brandtstdter, J., & Rothermund, K. (1994). Self-percepts of control in middle and later adulthood: Buffering losses by rescaling goals. Psychology and Aging, 9(2), 265273.
2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

43

Brandtstdter, J., & Rothermund, K. (2002). The life-course dynamics of goal pursuit and goal adjustment: A two-process framework. Developmental Review, 22(1), 117150. Carstensen, L.L. (1995). Evidence for a life-span theory of socioemotional selectivity. Current Directions in Psychological Science, 4(5), 151156. Charlson, M.E., Szatrowski, T.P., Peterson, J., & Gold, J. (1994). Validation of a combined comorbidity index. Journal of Clinical Epidemiology, 47(11), 1245 1251. Chaudhry, S., Jin, L., & Meltzer, D. (2005). Use of a self-report-generated Charlson Comorbidity Index for predicting mortality. Medical Care, 43(6), 607615. Cohen, S., & Wills, T.A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98(2), 310357. Deeg, D.J.H., Portrait, F., & Lindeboom, M. (2002). Health proles and prolespecic health expectancies of older women and men: The Netherlands. In S.B. Laditka (Ed.), Health expectations for older women: International perspectives (pp. 2746). New York: Haworth Press. Diener, E., Emmons, R.A., Larsen, R.J., & Grifn, S. (1985). The Satisfaction With Life Scale. Journal of Personality Assessment, 49(1), 7175. Diener, E., Kesebir, P., & Lucas, R. (2008). Benets of accounts of well-beingFor societies and for psychological science. Applied Psychology: An International Review. Special Issue: Health and Well-Being, 57, 3753. Diener, E., & Seligman, M.E.P. (2002). Very happy people. Psychological Science, 13(1), 8184. Diener, M.L., Diener McGavran, M.B., Eid, M., & Larsen, R.J. (2008). What makes people happy? A developmental approach to the literature on family relationships and well-being. In M. Eid & R.J. Larsen (Eds.), The science of subjective well-being (pp. 347375). New York: Guilford Press. Engstler, H., & Wurm, S. (2006). Datengrundlagen und Methodik [Data and methods]. In C. Tesch-Rmer, H. Engstler, & S. Wurm (Eds.), Altwerden in Deutschland: Sozialer Wandel und individuelle Entwicklungen in der zweiten Lebenshlfte (pp. 4783). Wiesbaden, Germany: VS Verlag. Fortin, M., Bravo, G., Hudon, C., Lapointe, L., Almirall, J., Dubois, M.-F. et al. (2006). Relationship between multimorbidity and health-related quality of life of patients in primary care. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation, 15(1), 8391. Fortin, M., Dubois, M.-F., Hudon, C., Soubhi, H., & Almirall, J. (2007). Multimorbidity and quality of life: A closer look. Health and Quality of Life Outcomes, 5, 52. Frederick, S., & Loewenstein, G. (1999). Hedonic adaptation. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-being: The foundations of hedonic psychology (pp. 302329). New York: Russell Sage Foundation. Freund, A.M., & Baltes, P.B. (2002). Life-management strategies of selection, optimization and compensation: Measurement by self-report and construct validity. Journal of Personality and Social Psychology, 82(4), 642662. Fried, L.P. (2000). Epidemiology of aging. Epidemiologic Reviews, 22(1), 95106. Hautzinger, M., & Bailer, M. (1993). Allgemeine Depressionsskala. Weinheim: Beltz.

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

44

SCHZ ET AL.

Kriegsman, D.M., Deeg, D.J.H., & Stalman, W.A.B. (2004). Comorbidity of somatic chronic diseases and decline in physical functioning: The Longitudinal Aging Study Amsterdam. Journal of Clinical Epidemiology, 57, 5565. Kunzmann, U., Little, T.D., & Smith, J. (2000). Is age-related stability of subjective well-being a paradox? Cross-sectional and longitudinal evidence from the Berlin Aging Study. Psychology and Aging, 15(3), 511526. Laux, G., Kuehlein, T., Rosemann, T., & Szecsenyi, J. (2008). Co- and multimorbidity patterns in primary care based on episodes of care: Results from the German CONTENT project. BMC Health Services Research, 8, 14. Lo, Y., Mendell, N.R., & Rubin, D.B. (2001). Testing the number of components in a normal mixture. Biometrika, 83(3), 767778. Lckenhoff, C.E., & Carstensen, L.L. (2004). Socioemotional selectivity theory, aging, and health: The increasingly delicate balance between regulating emotions and making tough choices. Journal of Personality, 72(6), 13951424. Lucas, R.E. (2007). Long-term disability is associated with lasting changes in subjective well-being: Evidence from two nationally representative longitudinal studies. Journal of Personality and Social Psychology, 92(4), 717730. Maslow, A.H. (1954). Motivation and personality. New York: Harper & Row. Meyer, D., Leventhal, H., & Gutmann, M. (1985). Common-sense models of illness: The example of hypertension. Health Psychology, 4(2), 115135. Muthn, L.K., & Muthn, B.O. (2007). MPlus users guide (5th edn.). Los Angeles, CA: Muthn & Muthn. Niv, D., & Kreitler, S. (2001). Pain and quality of life. Pain Practice, 1(2), 150 161. Pavot, W., & Diener, E. (1993). Review of the Satisfaction With Life Scale. Psychological Assessment, 5(2), 164172. Portrait, F., Lindeboom, M., & Deeg, D. (1999). Health and mortality of the elderly: The grade of membership method, classication and determination. Health Economics, 8(5), 441457. Portrait, F., Lindeboom, M., & Deeg, D. (2001). Life expectancies in specic health states: Results from a joint model of health status and mortality of older persons. Demography, 38(4), 525536. Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385401. Sattler, J.M. (1982). Age effects on Wechsler Adult Intelligence Scale-Revised Tests. Journal of Consulting and Clinical Psychology, 50(5), 785786. Schneeweiss, S., Wang, P.S., Avorn, J., & Glynn, R.J. (2003). Improved comorbidity adjustment for predicting mortality in Medicare populations. Health Services Research, 38(4), 11031120. Schwartz, C.E., Bode, R., Repucci, N., Becker, J., Sprangers, M.A.G., & Fayers, P.M. (2006). The clinical signicance of adaptation to changing health: A meta-analysis of response shift. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation, 15(9), 15331550. Smith, J., Fleeson, W., Geiselmann, B., Settersten, R.A., Jr., & Kunzmann, U. (1999). Sources of well-being in very old age. In P.B. Baltes (Ed.), The Berlin Aging Study: Aging from 70 to 100 (pp. 450471). New York: Cambridge University Press.

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.

HEALTH AND SUBJECTIVE WELL-BEING

45

Taylor, A.M. (2008). Cardiometabolic risk management in type 2 diabetes and obesity. Current Diabetes Reports, 8(5), 345352. Tooth, L., Hockey, R., Byles, J., & Dobson, A. (2008). Weighted multimorbidity indexes predicted mortality, health service use, and health-related quality of life in older women. Journal of Clinical Epidemiology, 61(2), 151159. van den Akker, M., Buntinx, F., Metsemakers, J.F.M., Roos, S., & Knotterus, J.A. (1998). Multimorbidity in general practice: Prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. Journal of Clinical Epidemiology, 51(5), 367375. Ware, J.E., & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30, 473483. Watson, D., Clark, L.A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54(6), 10631070. Wechsler, D. (1981). Manual for the Wechsler Adult Intelligence Scale-Revised (WAIS-R). San Antonio, TX: The Psychological Corporation. Weinstein, N.D., Rothman, A.J., & Sutton, S.R. (1998). Stage theories of health behavior: Conceptual and methodological issues. Health Psychology, 17(3), 290 299. Whitebourne, S.K. (2001). Differential aging. In International Encyclopedia of Social and Behavioral Sciences (pp. 36543658). Oxford: Pergamon. Windle, G., & Woods, R.T. (2004). Variations in subjective wellbeing: The mediating role of a psychological resource. Ageing and Society, 24(4), 583602. World Health Organization. (1946). The constitution of the World Health Organization. WHO Chronicle, 1, 21. World Health Organization. (1993). WHOQoL Study Protocol. New York: WHO. Wrosch, C., Scheier, M.F., Miller, G.E., Schulz, R., & Carver, C.S. (2003). Adaptive self-regulation of unattainable goals: Goal disengagement, goal reengagement, and subjective well-being. Personality and Social Psychology Bulletin, 29(12), 1494 1508.

2009 The Authors. Journal compilation 2009 International Association of Applied Psychology.