Social Indicators Research (2006) 77: 521–548 Ó Springer 2006

DOI 10.1007/s11205-005-7746-y

GRAEME HAWTHORNE

MEASURING SOCIAL ISOLATION IN OLDER ADULTS:

DEVELOPMENT AND INITIAL VALIDATION OF THE
FRIENDSHIP SCALE

(Accepted 23 May 2005)

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

KEY WORDS: loneliness, social connectedness, social isolation, social

relationships, social support

INTRODUCTION

Social isolation refers to living without companionship, social sup-

port or social connectedness. It is the absence of significant others
someone interrelates with, trusts, and turns to in time of crisis. It is
associated with poorer health-related quality of life (HRQoL), life
meaning, levels of satisfaction, wellbeing and community involve-
ment (Cantor and Sanderson 1999). The socially isolated suffer worse
health status, have a higher consumption of health care resources
(Ellaway et al., 1999) and have poorer outcomes from acute inter-
ventions, such as cardiovascular surgery (Ruberman et al., 1984;
522 GRAEME HAWTHORNE

Williams et al., 1992; Farmer et al., 1996). In addition there are

associations between social isolation and mental illness, distress,
dementia, suicide and premature death (Berkman and Syme, 1979;
Turner, 1981; House et al., 1982; Lester and Yang, 1992; Kawachi
et al., 1996; Fratiglioni et al., 2000; Rokach, 2000; Ellis and Hickie,
2001).
The key correlate of social isolation is personal relationships
(Polansky, 1985; Maxwell and Coebergh, 1986; Dykstra, 1990, 1995;
Mullins et al., 1996; Plopa, 1996; Gierveld, 1998). Other correlates
include network characteristics such as neighbourhood friendliness
and social initiation, geographic location, living alone or homeless-
ness, and ethnicity (Polansky, 1985; Cutrona, 1986; Lewin Epstein,
1991; Straits Troester et al., 1994; Mullins et al., 1996; Scheier and
Botvin, 1996; Gallagher et al., 1997; Gierveld, 1998). Both physical
and mental health status are also predictive of social isolation (Cobb,
1976; Thoits, 1982; Mullins et al., 1996; Plouffe and Jomphe Hill,
1996), as are aging communication losses (Retsinas and Garrity,
1985; Maxwell and Coebergh, 1986). Other correlates include eco-
nomic resources such as employment status and income (Polansky,
1985; Maxwell and Coebergh, 1986; Lewin Epstein, 1991; Mullins
et al., 1996; De Jong-Gierveld and van Tilburg, 1999).
It is widely accepted that the prevalence of social isolation is be-
tween 3–25%. It is a stereotype of later life that there is a network of
loneliness, social isolation and neglect (Victor et al., 2000; Baltes and
Smith, 2002) related to difficulties with mild cognitive impairment,
performing activities of daily living, declining health status, partner
loss, and institutionalization (van Oostrom et al., 1995).
The measurement of social isolation is important in studies of
older adults because it may influence their participation in and re-
sponse to public health interventions as well as being an outcome in
its own right. There are, however, several barriers to its measurement;
a major barrier may be questionnaire length.
As evaluation of public health interventions becomes routine,
instrument batteries are increasingly being used. Given that many
elderly people are frail, it is important that batteries are as parsi-
monious as possible to minimise response resistance since this cor-
relates with questionnaire length (Dillman, 1978; Yammarino et al.,
1991). Additionally, there are psychometric reasons for parsimony
related to the validity of measurement. These two issues suggest it is
 DEVELOPING THE FRIENDSHIP SCALE 523

important to develop short measures (Pedhazur and Schmelkin,

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

METHODS

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

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

The first cohort was older adults living in supported accommo-

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

Measures
The questionnaire package comprised the WHOQOL-Brèf, questions
from the proposed FS, the 4-item version of the Geriatric Depression
 DEVELOPING THE FRIENDSHIP SCALE 525

Scale (GDS, D’Ath et al., 1994), the Assessment of Quality of Life

(AQoL) utility measure (Hawthorne et al., 1999, 2001), the SF-12
health status scale (Ware et al., 1995), socio-demographic items and a
consent form.
The 4-item version of the GDS (D’Ath et al., 1994) was designed
for screening elderly patients in general practice to identify those with
depression. It comprises 4 dichotomous items. The cutpoints are ‘1’
indicating an uncertain diagnosis and ‘2’ indicating probable
depression.
The WHOQOL-Brèf is a QoL instrument comprising 24 items in
four domains: Physical (7 items), Psychological (6 items), Social (3
items) and Environment (8 items) (WHOQoL Group, 1996, 1998).
Additionally, there are two global ‘overall QoL’ items. All items are
rated on a 5-point scale, scoring is by summation and scores are
presented as percentages. The WHOQOL-Brèf has been used in
studies of mental health and aging (Herrman et al., 2002a; Amir and
Lev-Wiesel, 2003; Chan et al., 2003).
The Assessment of Quality of Life (AQoL) utility instrument
comprises five dimensions: Illness, Independent Living, Social Rela-
tionships, Physical Senses and Psychological Wellbeing (Hawthorne
et al., 1999, 2000). It uses the latter four for computing the utility
score ranging from )0.04 (worst possible HRQoL) to 0.00 (death
equivalent HRQoL) to 1.00 (full HRQoL). It has previously been
used in studies of aging (Osborne et al., 2003) and mental health
conditions (Goldney et al., 2000b; Herrman et al., 2002a; Hawthorne
et al., 2003).
The SF-12 has 12 items, which are weighted during scoring for
their contribution to either physical (PCS) or mental health (MCS)
(Ware et al., 1995; Ware et al., 1996). Items are concerned with the
performance of particular functions. PCS and MCS scores are pre-
sented as T-scores (McCall, 1922) where the norms are 50 (sd = 10).
US weights have been used. The SF-12 has been used in mental health
and older adults studies (Everard et al., 2000; Taylor et al., 2000;
Herrman et al., 2002b; Jackson and Burgess, 2002).

Friendship Scale items

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

support, which may be grouped into three key theories: (a) that the
social milieu affects responses to stress and that where there is a mis-
match in social milieu fit, stress may lead to health conditions (Cassel,
1976); (b) that social support provides a ‘buffer’ when people are in
crisis, thus the absence of social support may remove this buffer
leading to health conditions (Cobb, 1976); and (c) attachment theories
which state that childhood experiences predispose adult social network
behaviour (Bowlby, 1971). Clearly, all three theories are related.
Based on these theories, social isolation can be defined as living
without companionship, having low levels of social contact, little
social support, feeling separate from others, being an outsider, iso-
lated and suffering loneliness.
This definition suggests that there are seven dimensions to the
construct, and that social isolation can occur where these are trans-
gressed. These dimensions, drawn from the literature, are: (a) an
absence of sharing of feelings or being intimate with a significant
other or others (Weiss, 1974; Russell et al., 1980; Cutrona, 1986;
Sherbourne and Stewart, 1991; Lugton, 1997; Hawthorne et al., 1999;
Smith, 2003); (b) the (in)ability to relate to others (not just the ab-
sence of opportunity) with a particular emphasis on what it is that the
relationship provides (Henderson et al., 1980; Rose et al., 2000;
Lauber et al., 2004); (c) being unable to ask others for support when
it is needed, perhaps due to the perception of being a burden to others
(Sarason et al., 1987a; Sherbourne and Stewart, 1991; WHOQoL
Group, 1998; Kissane et al., 2001); (d) having no social networks,
regardless of whether these are for receiving or giving support
(Sarason et al., 1987a; Lee and Robbins, 1995; Victor et al., 2000); (e)
being separate or isolated from others in social settings, including
being unable to perform social roles (Ware et al., 1993; Hawthorne
et al., 1999; Rokach, 2000); (f) being isolated from others, whether
through difficulties in communication or social inadequacy (Lee and
Robbins, 1995; Lugton, 1997; Victor et al., 2000); and (g) being alone
or suffering loneliness, including how a person perceives their posi-
tion in relation to others (Russell et al., 1980; Sarason et al., 1987a;
Rokach, 2000; Victor et al., 2000).
Obviously, social isolation is a multidimensional construct, and
each of these dimensions should be measured in a comprehensive
instrument. There are numerous operationalizations of this construct,
as the following few examples show. The UCLA Loneliness Scale
 DEVELOPING THE FRIENDSHIP SCALE 527

measures personal and social levels of relationships (Russell, 1982;

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

Perhaps the issues above explain Bowling’s conclusion made over

10 years ago but seemingly still applicable that ‘‘There is currently no
assessment scale which comprehensively measures the main compo-
nents of social network and support with acceptable levels of reli-
ability and validity’’ (Bowling, 1991, p. 122). A key issue which might,
perhaps, partly explain this situation relates to the perspective of
measurement. The studies reviewed above may be grouped into those
that provide objective assessments of social isolation based on
observation of social conditions (e.g. for a review see Berkman and
Glass (2000)) and those that assess it from the individual’s perspective,
i.e. perceived social support (e.g. see Sarason et al. (1987b)). Whilst
both perspectives are valid, the position taken in this paper is that it is
the subjective experience of the individual that has primacy. This
perspective is consistent with the World Health Organization’s com-
mitment to the individual’s perception of their position in life in the
context of the culture and value systems in which they live and in
relation to their goals, expectations, standards and concerns (WHO-
QoL Group, 1993).
Items from the instruments cited above were reviewed and de novo
items covering each of the seven dimensions written. To ensure
simplicity, item stems were made short and friendly, like those in the
Social Connectedness Scale (Lee and Robbins, 1995) and the
Nottingham Health Profile (Hunt et al., 1981; Hunt et al., 1985;
Hunt et al., 1989). To reduce response resistance to items that may
confront respondents with an awareness of their losses, items were
written from the point of view of having friends and social support.
To prevent acquiescent response bias (Crowne and Marlowe, 1960;
Furnham and Henderson, 1982) a mixture of positive and negative
items were written. During item construction, several different ver-
sions were constructed and considered. These were iteratively
reviewed by both older adults and the authors’ colleagues and
modified until final versions were agreed.
Regarding item responses, a Guttman-type response scale was
prepared because most people do not experience isolation. To over-
come end aversion the worst possible outcome (no social interaction
at all) was represented by the lowest level on the response scale,
recognising this implied that few people would actually endorse this
level.
 DEVELOPING THE FRIENDSHIP SCALE 529

Finally, the timeframe was set at 4 weeks because this provided an

estimate that was stable rather than one which fluctuated where a
short timeframe was specified, yet not so long as to involve issues of
memory recall or distortion.
The final version of the Friendship Scale (FS) is presented in the
Appendix. Scoring involves reversal of items 1, 3 and 4 followed by
summation across all items. The score range is 0–24. A high score
represents social connectedness and a score of ‘‘0’’ complete social
isolation. A computerized scoring algorithm is available from the
author.

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

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

RESULTS

Of the 829 participants, 57% were female and the mean age was
75 years (sd = 9 years). Three percent were single, 60% married or
partnered, 5% divorced or separated and 32% were widowed.
Nineteen percent had completed primary school, 39% high school,
16% held a trade certificate and 26% a diploma or degree. Thirty-
four percent were living at home, 52% were living at home with
support (by their family or carer) and 14% were in residential
accommodation (in residential care, hostel or nursing home). Twen-
ty-two percent were working, 75% were retired or were the home-
maker and 4% were unable to work because of illness or disability.
Five percent were in excellent health, 19% in very good health,
31% in good health, 29% in fair health and 16% in poor health. The
mean SF-12 MCS was 51.79 (sd = 9.75) suggesting participants were
in good mental health, and for the PCS it was 43.40 (sd=10.43)
which suggested fair physical health. Regarding quality of life, for the
WHOQOL-Brèf Physical domain the mean was 65.98 (sd=18.09),
for the Psychological domain it was 66.89 (sd=14.33), for the Social
domain it was 68.55 (sd=18.15) and for the Environment domain it
was 73.50 (sd=13.05). The mean AQoL utility score was 0.64
(sd=0.26). For both the WHOQOL-Brèf and AQoL, the scores were
below population norms, suggesting a limited quality of life (Haw-
thorne et al. in press; Hawthorne and Osborne, 2005).
For the construction sample, the PCA results showed that six of
the seven items formed a unidimensional scale with mean loadings
between 0.63 and 0.84. The mean for the seventh item (Item 5: Others
felt they had to help me) was 0.34. The IRTCs showed a similar
pattern, as shown in Table 1. These results indicated this item was
not substantially contributing, so it was deleted. Following deletion,
the Cronbach a was 0.81 for the remaining 6 items compared with
 DEVELOPING THE FRIENDSHIP SCALE 531

0.76 for all 7 items. The 6 remaining items were numbered 1–6 for
convenience.
These 6 items were examined using the validation sample. The
SEM model is presented in Figure 1, which indicates the items
formed a robust model with excellent statistical properties.
Partial credit IRT ascertained the order in which social losses are
endorsed (IRT model statistics: v2 for parameter equality = 363.69,
p < 0.01, Separation reliability = 0.99). The difficulty estimates ex-
pressed in logits were: Item 1: )0.24 (weighted T = 0.1); Item 2:
)0.34 ()4.8); Item 3: 0.97 (3.4); Item 4: 0.22 (0.9); Item 5: )0.07
()2.7), and Item 6: )0.61 (constrained item).
Using all cases in the study, the Spearman correlations between
items ranged from 0.29 (items 1 and 5) to 0.59 (items 2 and 6). The
distribution of FS scores is presented in Figure 2. This shows that
50% of participants obtained scores in the range 20–24, indicating
that they were not socially isolated. Other participants were spread
over the FS range. For the 6 FS items, Cronbach a = 0.83.
The FS was correlated with the SF-12 MCS and PCS scales, the
WHOQOL-Brèf domains and AQoL dimensions (Table II). The FS
was significantly more correlated with the SF-12 MCS when com-
pared with the PCS (Cohen’s q = 0.18, p < 0.01). For the WHO-
QOL-Brèf, the highest correlation was with the Psychological domain
when compared with the Physical and Environment domains
(q = 0.17 and 0.11, p < 0.05, respectively). There were no other
significant differences. For the AQoL, the highest correlation was
with the Social Relationship dimension (q = 0.49 for Illness, 0.41 for
Independent Living, 0.44 for Physical Senses and 0.32 for Psycho-
logical Wellbeing, p < 0.01 for all). Psychological Wellbeing was also
more highly correlated with the FS than Illness (q = 0.16, p < 0.01)
or Physical Senses (q = 0.12, p = 0.05).
Table III presents discriminatory tests of the FS by correlates of so-
cial isolation: accommodation, work status, community involvement,
wellbeing, marital status, and depression. As shown, on all measures the
FS discriminated as expected. Although not reported in the table, for
those living in a nursing ward (n = 5) the mean FS score was 12.22,
suggesting a high level of social isolation. The table also includes an
analysis by study cohort, showing there were significant differences,
although the OUT and MAR cohorts obtained very similar scores.
532 GRAEME HAWTHORNE

TABLE I
Scale analysis of the Friendship Scale item pool: results of 20 random
iterations (50% of construction cases)

Items EFA (Principal Reliability analysis

component) (IRTCa)

Mean 95% CIs Mean 95% CIs

1 It has been easy to 0.64 (0.62–0.66) 0.50 (0.48–0.52)

relate to others
2 I felt isolated from 0.81 (0.80–0.81) 0.66 (0.64–0.67)
other people
3 I had someone 0.64 (0.63–0.66) 0.48 (0.46–0.49)
to share my feelings with
4 I found it easy to get in 0.72 (0.71–0.74) 0.56 (0.55–0.58)
touch with others when
I needed to
Others felt they had 0.34 (0.32–0.37) 0.23 (0.21–0.25)
to help me
5 When with other people 0.74 (0.73–0.76) 0.57 (0.55–0.59)
I felt separate from them
6 I felt alone and friendless 0.83 (0.82–0.84) 0.67 (0.66–0.69)
Eigenvalue 3.36 (3.30–3.42)
% Variance 64.53 (63.71–65.34)
Cronbach a 0.76 (0.75–0.77)
a
Item-rest-of-test correlation.

FS scores can be categorised into five levels. Those who are very
socially isolated will obtain scores in the range 0–11 because they will
have endorsed at least 1 item at level 1 or lower (i.e. have reported an
isolating condition ‘‘most of the time’’ or ‘‘almost always’’). Isolated
or low level social support respondents are those with scores of 12–
15, which require endorsement of at least two items at or lower than
level 2. Some social support refers to the range 16–18, because in this
range at least two items at level 3 or lower must be endorsed. The
socially connected range is between 19–21 because at least one item at
level 3 or lower must be endorsed. The very socially connected will
score within the range 22–24. This requires endorsement of at least
four items at level 4. A person obtaining a score in this range cannot
have endorsed any item at levels 0 or 1.
Based on this classification, 4% of the sample obtained scores
indicating they were socially isolated, 11% were isolated with low
 DEVELOPING THE FRIENDSHIP SCALE 533

Easy to relate to others 0.36 E1

0.60
Isolated from others 0.69 E2
0.23
0.83

Someone to share with 0.25 E3

0.50 0.34
Social
Isolation 0.56 Easy to get in touch 0.31 E4

0.73
Felt separate from others 0.53 E5
0.78

Alone and friendless 0.60 E6

Figure 1. Structural equation model of the Friendship Scale items, based on

validation cohort.
Model shows standardised regression weights.
Statistics: N = 374, model = ADF, v2 = 8.18, df = 7, p = 0.32,
CFI = 0.99, RMSEA = 0.02 (95% CI: 0.00–0.07).

support, 17% had some support, 28% were socially connected and
40% were very socially connected. Using this scheme, for example,
those who were single, separated, divorced or widowed (n = 326)
were twice as likely as those who were partnered (n = 480) to report
they were socially isolated or had low social support (OR: 2.16; 95%
CI: 1.44–3.25).
250

200

150
Frequency

100

50

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

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

534 GRAEME HAWTHORNE

TABLE II
Concurrent validation with the SF-12, WHOQOL-Brèf and AQoL scales

Friendship scale

N rs

SF-12 Physical (PCS) 808 0.21*

Mental (MCS) 808 0.37*
WHOQOL-Brèf Physical 808 0.34*
Psychological 811 0.48*
Social 798 0.44*
Environment 811 0.39*
AQoL Medication use 784 0.22*
Independent living 784 0.29*
Social relationships 794 0.61*
Physical senses 802 0.26*
Psychological 802 0.37*
wellbeing
AQoL utility 771 0.53*

*p < 0.01.

DISCUSSION

Although there are many scales measuring social isolation, in general

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

N Friendship Scale Statisticsa

scores

Mean sd

Accommodation At home, supported 399 20.27 3.93

At home, unsupported 264 19.47 3.99
Family, sheltered 30 18.60 3.61
housing or community
care
Residential care/ 79 17.22 4.49 F = 15.47, df = 3,768, p < 0.01
Nursing home
Work status In the workforce 162 19.99 3.50
Disabled/sick 30 16.37 5.45
Retired/homemaker 555 19.91 3.95 F = 8.84, df = 2,744, p < 0.01
SF-12 Item All the time 20 15.80 4.92
12: Health interfered Most of the time 44 15.93 5.60
with social activities Some of the time 128 17.03 4.44
DEVELOPING THE FRIENDSHIP SCALE

A little of the time 154 19.03 3.52

None of the time 459 20.88 3.23 F = 38.14, df = 4,800, p < 0.01
WHOQOL-Brèf Very dissatisfied 34 16.74 4.83
Item 2: Satisfaction Fairly dissatisfied 107 17.67 4.48
with health status Neither 183 18.85 4.03
Satisfied 380 20.44 3.54
535

Very satisfied 98 21.03 3.76 F = 22.03, df = 4,797, p < 0.01

 TABLE III
536
(Continued)

N Friendship Scale Statisticsa

scores

Mean sd

Marital status Single 27 16.37 6.01

Partnered 480 20.34 3.80
Separated/Divorced 39 18.00 4.30
Widowed 260 18.83 3.91 F = 16.88, df = 3,802, p < 0.01
GDS Not depressed 596 20.43 3.45
Uncertain 70 19.21 3.80
Probably depressed 62 14.13 4.83 F = 62.94, df = 2,725, p < 0.01
Study cohort HOS – hostel 92 17.37 4.29
OUT – outpatients 67 19.28 3.73
MAR – magazine 129 18.78 4.64
GRAEME HAWTHORNE

COR – community 528 20.26 3.73 F = 16.68, df = 3,812, p < 0.01

a
ANOVA, data analyses on transformed data.
 DEVELOPING THE FRIENDSHIP SCALE 537

rs, upon which PCA is based, will underestimate correlations where

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

intimacy (item 3), getting in touch with others (item 4), feeling separate
(item 5), ease in relating to others (item 1) and feeling isolated (item 2).
Admitting to being alone (item 6) was the hardest item for respondents
to endorse. The weighted fit T-values suggested diversity among the
items, more so than would be normally acceptable in a unidimensional
scale. This is understandable given that the items were designed to
measure different dimensions of social isolation; it should not be ex-
pected that the items would closely cluster on unidimensional tests.
That the item difficulties were spread out over the range +0.97 to )0.61
implies that they provide a broad coverage of social isolation; a feature
which ensures people with all levels of social support will find the FS
relevant (Streiner and Norman, 1995).
The test of concurrent validation against the SF-12 PCS and MCS,
the WHOQOL-Brèf domains and AQoL dimensions provides further
validity evidence. Regarding the AQoL Social Relationships scale,
the correlation with the FS was almost double that of any other
AQoL dimension, suggesting that the FS and Social scales were
measuring similar concepts. The correlations with the WHOQOL-
Brèf domains were not so clear-cut. That the Friendship Scale cor-
related most highly with the Psychological domain rather than the
Social Relationships domain may be explained by known difficulties
with the sex item in this scale (Norholm and Bech, 2001; Min et al.,
2002). The correlation between the FS and the sex item was r = 0.25.
This suggests that satisfaction with one’s sex life, particularly in older
adults, may not be closely related to social isolation (e.g. consider the
situation where a person has no or little sex drive or life).
That the two measures of social role, the AQoL Social scale
(Table II) and the SF-12 social activities question (Table III) were
both highly correlated with the FS suggests that the FS is measuring
social isolation in relation to how a person feels about themselves,
their social role and their need for belongingness. It may also suggest
that the quality of and satisfaction with relationships or social con-
tacts is as important as the contacts themselves (Stansfeld, 1999;
Fratiglioni et al., 2000).
The correlations with the SF-12 MCS, WHOQOL-Brèf Psycho-
logical domain and the difference in FS scores by GDS classification
suggest that there may be a strong mental health effect on social
isolation. This is consistent with other research showing a graded
relationship between mental health, particularly depression, and
 DEVELOPING THE FRIENDSHIP SCALE 539

social relationships (Cobb, 1976; Thoits, 1982; Goldney et al.,

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

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

CONCLUSION

This study has reported on the development and preliminary vali-

dation of a short, user-friendly scale measuring perceived social iso-
lation, the Friendship Scale. The items measure six of the seven
dimensions contributing to social isolation. Its psychometric prop-
erties suggest that it has excellent internal structures and that it
possesses reliability and discrimination.
Although further work is needed to validate it in other popula-
tions, the results of the current study suggest that researchers may
find it particularly useful in epidemiology, population surveys or in
health-related quality of life evaluation studies where a parsimonious
measure of social isolation or support is needed.

ACKNOWLEDGEMENTS

I would like to thank the many researchers who have contributed to

this study. My thanks go to Professor Edmund Chiu, Pippa Grif-
fiths, Dr. Barbara Murphy, Rob Winther and Dr. Kathryn Quinn
 DEVELOPING THE FRIENDSHIP SCALE 541

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

APPENDIX
The Friendship Scale

During the past four weeks:

*1. It has been easy to 2. I felt isolated from other people:
relate to others:
h Almost always h Almost always
h Most of the time h Most of the time
h About half the time h About half the time
h Occasionally h Occasionally
h Not at all h Not at all
*3. I had someone to share *4. I found it easy to get in touch
my feelings with: with others when I needed to:
h Almost always h Almost always
h Most of the time h Most of the time
h About half the time h About half the time
h Occasionally h Occasionally
h Not at all h Not at all
542 GRAEME HAWTHORNE
APPENDIX
(Continued)

During the past four weeks:

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

REFERENCES

Amir, M. and R. Lev-Wiesel: 2003, Time does not heal all wounds: quality of life and
psychological distress of people who survived the holocaust as children 55 years
later, Journal of Traumatic Stress 16, pp. 295–299.
Anastasi, A.: 1986, Evolving concepts of test validation, Annual Review of Psy-
chology 37, pp. 1–15.
Andrich, D.: 1978, A rating formulation for ordered response categories, Psycho-
metrika 43, pp. 561–573.
Arbuckle, J. and W. Wothke: 1999, Amos (Small Waters Corporation, Chicago).
Baltes, P. B. and J. Smith: 2002, New Frontiers in the Future of Aging: From
Successful Aging of the Young old to the Dilemmas of the Fourth Age (Max Plant
Institute for Human Development, Berlin).
Berkman, L. and T. Glass: 2000, Social Integration, Social Networks, Social Sup-
port, and Health, in L. Berkman and I. Kawachi (eds.), Social Epidemiology
(Oxford University Press, Oxford), pp. 137–173.
Berkman, L. and L. Syme: 1979, Social networks, host resistance and mortality: a
nine-year follow-up study of Alameda County residents, American Journal of
Epidemiology 109, pp. 186–204.
Bowlby, J.: 1971, Attachment (Pelican, London).
Bowling, A.: 1991, Measuring Health: A Review of Quality of Life Measurement
Scales (Open University, Milton Keynes).
Browne, M. W. and R. Cudeck: 1993, Alternative Ways of Assessing Model Fit, in
K. A. Bollen and J. S. Long (eds.), Testing Structural Equation Models (Sage,
Newbury Park), pp. 136–162.
Cantor, N. and C. Sanderson: 1999, Life task participation and well-being: the
importance of taking part in daily life, in D. Kahneman, E. Diener and N. Sch-
warz (eds.), Well-Being: The Foundations of Hedonic Psychology (Russell Sage
Foundation, New York), pp. 230–243.
Cassel, J.: 1976, The contribution of the social environment to host resistance: the
Fourth Wade Hampton Frost Lecture, American Journal of Epidemiology 104,
pp. 107–23.
Chan, G. W., G. S. Ungvari, D. T. Shek and J. J. Leung Dagger: 2003, Hospital and
community-based care for patients with chronic schizophrenia in Hong Kong
 DEVELOPING THE FRIENDSHIP SCALE 543

Quality of life and its correlates, Social Psychiatry and Psychiatric Epidemiology
38, pp. 196–203.
Cobb, S.: 1976, Social support as a moderator of life stress, Psychosomatic Medicine
317, pp. 300–314.
Cronbach, J. and P. Meehl: 1955, Construct validity in psychological tests, Psy-
chological Bulletin 52, pp. 281–302.
Crowne, D. and D. Marlowe: 1960, A new scale for social desirability independent of
psychopathology, Journal of Counselling Psychology 24, pp. 349–354.
Cutrona, C.: 1986, Objective determinants of perceived social support, Journal of
Personality and Social Psychology 50, pp. 349–355.
D’Ath, P., P. Katona, E. Mullan, S. Evans and C. Katona: 1994, Screening, detec-
tion and management of depression in elderly primary care attenders. I: The
acceptability and performance of the 15 item Geriatric Depression Scale (GDS15)
and the development of short versions, Family Practice 11, pp. 260–266.
De Jong-Gierveld, J. and T. van Tilburg: 1999, Living arrangements of older adults
in the Netherlands and Italy: coresidence values and behaviour and their conse-
quences for loneliness, Journal of Cross Cultural Gerontology 14, pp. 1–24.
Dillman, D.: 1978, Mail and Telephone Surveys: the Total Design Method (Wiley,
New York).
Dykstra, P.: 1990, Next of (non)kin: The Importance of Primary Relationships for
Older Adults’ Well-Being (Swets and Zeitlinger, Lisse).
Dykstra, P.: 1995, Loneliness among the never and formerly married: The impor-
tance of supportive friendships and a desire for independence, Journals of Ger-
ontology: Series B: Psychological Sciences and Social Sciences 50B, S321–S329.
Ellaway, A., S. Wood and S. MacIntyre: 1999, Someone to talk to? The role of
loneliness as a factor in the frequency of GP consultations, British Journal of
General Practice 49, pp. 363–367.
Ellis, P. and I. Hickie: 2001, What causes mental illness?, in S. Bloch and
B. Singh (eds.), Foundations of Clinical Psychiatry (Melbourne University Press,
Melbourne), pp. 43–62.
Everard, K. M., H. W. Lach, E. B. Fisher and M. C. Baum: 2000, Relationship of
activity and social support to the functional health of older adults, Journal of
Gerontology: Series B: Psychological Sciences and Social Sciences 55, pp. S208–
S212.
Farmer, I., P. Meyer, D. Ramsey, D. Goff, M. Wear, D. Labarthe and
M. Nichaman: 1996, Higher levels of social support predict greater survival fol-
lowing acute myocardial infarction: the Corpus Christi Heart Project, Behavioural
Medicine 22, pp. 59–66.
Folstein, M., S. Folstein and P. McHugh: 1975, ‘Mini-Mental State’: a practical
method for grading the cognitive state of patients for the clinician, Journal of
Psychiatric Research 12, pp. 189–198.
Fratiglioni, L., H. Wang, K. Ericsson, M. Maytan and B. Winblad: 2000, Influence
of social network on occurrence of dementia: a community-based longitudinal
study, Lancet 355, pp. 1315–1319.
Furnham, A. and M. Henderson: 1982, The good, the bad and the mad: response bias
in self-report measures, Personality and Individual Differences 3, pp. 311–320.
Gallagher, T., R. Andersen, P. Koegel and L. Gelberg: 1997, Determinants of reg-
ular source of care among homeless adults in Los Angeles, Medical Care 35, pp.
814–830.
544 GRAEME HAWTHORNE

Gierveld, J.: 1998, A review of loneliness: concept and definitions, determinants and
consequences, Reviews in Clinical Gerontology 8, pp. 73–80.
Goldney, R., L. Fisher, D. Wilson and F. Cheok: 2000a, Major depression and its
associated morbidity and quality of life in a random, representative Australian
community sample, Australian and New Zealand Journal of Psychiatry 34, pp.
1022–1029.
Goldney, R. D., D. Wilson, E. Dal Grande, L. J. Fisher and A. C. McFarlane:
2000b, Suicidal ideation in a random community sample: attributable risk due to
depression and psychosocial and traumatic events, Australian and New Zealand
Journal of Psychiatry 34, pp. 98–106.
Hawthorne, G., F. Cheok, R. Goldney and L. Fisher: 2003, The excess cost of
depression in South Australia: a comparative study of two methods of calculating
burden, Australian and New Zealand Journal of Psychiatry 37, pp. 362–373.
Hawthorne, G., H. Herrman, and B. Murphy: In Press, Interpreting the WHOQOL-
Brèf: preliminary population norms and effect sizes. Social Indicators Research
(Accepted April 2005).
Hawthorne, G. and A. Hogan: 2002, Measuring disability-specific patient benefit in
cochlear implant programs: developing a short form of the Glasgow Health Status
Inventory, the Hearing Participation Scale, International Journal of Audiology
41, pp. 535–44.
Hawthorne, G. and R. Osborne: 2005, Population norms and meaningful differences
for the Assessment of Quality of Life (AQoL) measure, Australian and New
Zealand Journal of Public Health 29, pp. 136–142.
Hawthorne, G., J. Richardson and N. A. Day: 2001, A comparison of the Assess-
ment of Quality of Life (AQoL) with four other generic utility instruments, Annals
of Medicine 33, pp. 358–370.
Hawthorne, G., J. Richardson and R. Osborne: 1999, The Assessment of Quality of
Life (AQoL) instrument: a psychometric measure of health related quality of life,
Quality of Life Research 8, pp. 209–224.
Henderson, S., P. Duncan-Jones, D. Byrne and R. Scott: 1980, Measuring social
relationships: the Interview Schedule for Social Interaction, Psychological Medi-
cine 10, pp. 723–734.
Herrman, H., G. Hawthorne and R. Thomas: 2002a, Quality of life assessment in
people living with psychosis, Social Psychiatry and Psychiatric Epidemiology 37,
pp. 510–518.
Herrman, H., D. L. Patrick, P. Diehr, M. L. Martin, M. Fleck, G. E. Simon and D.
P. Buesching: 2002b, Longitudinal investigation of depression outcomes in pri-
mary care in six countries: the LIDO study. Functional status, health service use
and treatment of people with depressive symptoms, Psychological Medicine 32,
pp. 889–902.
House, J., C. Robbins and H. Metzner: 1982, The association of social relationships
and activities with mortality: prospective evidence from the Tecumseh Community
Health Study, American Journal of Epidemiology 116, pp. 123–140.
Hunt, S., J. McEwan and S. McKenna: 1985, Measuring health status: a new tool for
clinicians and epidemiologists, Journal of the Royal College of General Practi-
tioners 35, pp. 185–188.
Hunt, S., S. McKenna and J. McEwen: 1989, The Nottingham Health Profile User’s
Manual (Galen Research & Consultancies, Manchester).
 DEVELOPING THE FRIENDSHIP SCALE 545

Hunt, S., S. McKenna, J. McEwen, J. Williams and E. Papp: 1981, The Nottingham
Health Profile: subjective health status and medical consultations, Social Science
and Medicine 15A, pp. 221–229.
Jackson, H. J. and P. M. Burgess: 2002, Personality disorders in the community:
results from the Australian National Survey of Mental Health and Wellbeing Part
II. Relationships between personality disorder, Axis I mental disorders and
physical conditions with disability and health consultations, Social Psychiatry and
Psychiatric Epidemiology 37, pp. 251–260.
Kawachi, I., G. Colditz, A. Ascherio, E. Rimm, E. Giovannucci, M. Stampfer and
W. Willett: 1996, A prospective study of social networks in relation to total
mortality and cardiovascular disease in men in the USA, Journal of Epidemiology
and Community Health 50, pp. 245–251.
Kissane, D. W., D. M. Clarke and A. F. Street: 2001, Demoralization syndrome – a
relevant psychiatric diagnosis for palliative care, Journal of Palliative Care 17, pp.
12–21.
Lauber, C., C. Nordt, L. Falcato and W. Rossler: 2004, Factors influencing social
distance toward people with mental illness, Community Mental Health Journal
40, pp. 265–74.
Lee, R. M. and S. B. Robbins: 1995, Measuring belongingness: the Social Con-
nectedness and the Social Assurance scales, Journal of Counseling Psychology 42,
pp. 232–241.
Lester, D. and B. Yang: 1992, Social and economic correlates of the elderly suicide
rate, Suicide and Life Threatening Behavior 22, pp. 36–47.
Lewin Epstein, N.: 1991, Determinants of regular source of health care in black,
Mexican, Puerto Rican, and non-Hispanic white populations, Medical Care 29,
pp. 543–557.
Lugton, J.: 1997, The nature of social support as experienced by women treated for
breast cancer, Journal of Advanced Nursing 25, pp. 1184–1191.
Masters, G.: 1982, A Rasch model for partial credit scoring, Psychometrika 47, pp.
149–174.
Maxwell, G. and B. Coebergh: 1986, Patterns of loneliness in a New Zealand pop-
ulation, Community Mental Health in New Zealand 2, pp. 48–61.
McCall, W. A.: 1922, How to Measure in Education (Macmillan, New York).
Midlarsky, E., E. Kahana, R. Corley, R. Nemeroff and R. A. Schonbar: 1999,
Altruistic moral judgment among older adults, International Journal of Aging and
Human Development 49, pp. 27–41.
Min, S. K., K. I. Kim, C. I. Lee, Y. C. Jung, S. Y. Suh and D. K. Kim: 2002,
Development of the Korean versions of WHO Quality of Life scale and WHO-
QOL-BREF, Quality of Life Research 11, pp. 593–600.
Mullins, L., C. Elston and S. Gutkowski: 1996, Social determinants of loneliness
among older Americans, Genetic, Social, and General Psychology Monographs
122, pp. 453–473.
Norholm, V. and P. Bech: 2001, The WHO Quality of Life (WHOQOL) Ques-
tionnaire: Danish validation study, Nordic Journal of Psychiatry 55, pp. 229–235.
Nunally, J.: 1967, Psychometric Theory (McGraw Hill, New York).
Osborne, R. H., G. Hawthorne, E. A. Lew and L. C. Gray: 2003, Quality of Life
assessment in the community-dwelling elderly: validation of the Assessment of
Quality of Life (AQoL) instrument and comparison with the SF-36, Journal of
Clinical Epidemiology 56, pp. 138–147.
546 GRAEME HAWTHORNE

Pedhazur, E. and L. Schmelkin: 1991, Measurement, Design and Analysis: An

Integrated Approach (Lawrence Erlbaum, Hillsdale).
Plopa, M.: 1996, Anxiety dynamics in sea isolation: family determinants, Polish
Psychological Bulletin 27, pp. 359–371.
Plouffe, L. and A. Jomphe Hill: 1996, Distressed and lonely: health and social
determinants among residents in seniors’ housing, Journal of Clinical Geropsy-
chology 2, pp. 51–60.
Polansky, N.: 1985, Determinants of loneliness among neglectful and other low-
income mothers, Journal of Social Service Research 8, pp. 1–15.
Reiser, M., M. Wallace and K. Schuessler: 1986, Direction-of-wording effects in
dichotomous social life feeling items, in N. Tuma (ed.), Sociological Methodology
(Jossey-Bass, San Francisco)..
Retsinas, J. and P. Garrity: 1985, Nursing home friendships, Gerontologist 25, pp.
376–381.
Rokach, A.: 2000, Loneliness and the life cycle, Psychological Reports 86, pp.
629–642.
Rose, L. E., J. Campbell and J. Kub: 2000, The role of social support and family
relationships in women’s responses to battering, Health Care for Women Inter-
national 21, pp. 27–39.
Ruberman, W., E. Weinblatt, J. Goldberg and B. Chaudhary: 1984, Psychosocial
influences on mortality after myocardial infarction, New England Journal of
Medicine 311, pp. 552–559.
Russell, D.: 1982, The measurement of loneliness, in L. Peplau and D. Perlman
(eds.), Loneliness: A Sourcebook of Current Theory, Research and Therapy (John
Wiley, New York), pp. 81–104.
Russell, D., C. Cutrona, J. Rose and K. Yurko: 1984, Social and emotional loneli-
ness: an examination of Weiss’s typology of loneliness, Journal of Personality and
Social Psychology 46, pp. 1313–1321.
Russell, D., L. Peplau and C. Cutrona: 1980, The revised UCLA Loneliness Scale:
concurrent and discriminant validity evidence, Journal of Personality and Social
Psychology 39, pp. 472–480.
Sarason, B. R., E. N. Shearin, G. R. Pierce and I. G. Sarason: 1987a, Interrelations of
social support measures: theoretical and practical implications, Journal of Per-
sonality and Social Psychology 52, pp. 813–832.
Sarason, I., B. Sarason, E. Shearin and G. Pierce: 1987b, A brief measure of social
suppport: practical and theoretical implications, Journal of Social and Personal
Relationships 4, pp. 497–510.
Scheier, L. and G. Botvin: 1996, Purpose in life, cognitive efficacy, and general
deviance as determinants of drug abuse in urban black youth, Journal of Child
and Adolescent Substance Abuse 5, pp. 1–26.
Sherbourne, C. and A. Stewart: 1991, The MOS social support survey, Social Science
and Medicine 32, pp. 705–714.
Smith, A. A.: 2003, Intimacy and family relationships of women with chronic pain,
Pain Management Nursing 4, pp. 134–42.
SPSS, 2003, SPSS for Windows 11.5 ed. (SPSS Inc, Chicago).
Stansfeld, S.: 1999, Social support and social cohesion, in M. Marmot, R. Wilkin-
son(eds.), Social Determinants of Health (Oxford University Press, Oxford), pp.
155–178.
 DEVELOPING THE FRIENDSHIP SCALE 547

Straits Troster, K., T. Patterson, S. Semple, L. Temoshok, P. Roth,

J. McCutchan, J. Chandler, I. Grant and The HNRC Group: 1994, The rela-
tionship between loneliness, interpersonal competence, and immunologic status in
HIV-infected men, Psychology and Health 9, pp. 205–219.
Streiner, D. and G. Norman: 1995, Health Measurement Scales: A Practical Guide
to their Development and Use (Oxford Medical Publications, Oxford).
Tabachnick, B. G. and L. S. Fidell: 2001, Using Multivariate Statistics (Harper
Collins, New York).
Taylor, A. W., D. H. Wilson, E. Dal Grande, D. Ben-Tovim, R. H. Elzinga, R. D.
Goldney, A. C. McFarlane, F. Cheok and K. Kirke: 2000, Mental health status of
the South Australian population, Australian and New Zealand Journal of Public
Health 21, pp. 20–34.
Thoits, P.: 1982, Conceptual, methodological and theroretical problems in studying
social support as a buffer against life stress, Journal of Health and Social
Behaviour 23, pp. 145–159.
Turner, R. J.: 1981, Social support as a contingency in psychological wellbeing,
Journal of Health and Social Behavior 22, pp. 357–367.
van Oostrom, M. A., M. A. Tijhuis, J. C. Van Haes, R. Tempelaar and
D. Kromhout: 1995, A measurement of social support in epidemiological re-
search: the social experiences checklist tested in a general population in The
Netherlands, Journal of Epidemiology and Community Health 49, pp. 518–24.
Victor, C., J. Bond, A. Bowling and S. Scambler: 2000, Growing older: The ESRC
Research Programme on Extending Quality of Life: Loneliness, Social Isolation
and Living Alone in Later Life. Electronic source: http://www.shef.ac.uk/uni/
projects/gop/gop21.html. Access date: 15 December 2000.
Ware, J., M. Kosinski and S. Keller: 1996, A 12-Item Short-Form Health Survey:
construction of scales and preliminary tests of reliability and validity, Medical
Care 34, pp. 220–233.
Ware, J., M. Kosinski and S. Keller: 1995, SF-12: How to Score the SF-12 Physical
and Mental Health Summary Scales (The Health Institute, New England Medical
Center, Boston).
Ware, J. E., K. K. Snow, M. Kosinski and B. Gandek: 1993, SF-36 Health Survey:
Manual and Interpretation Guide (The Health Institute, New England Medical
Centre, Boston).
Weiss, R.: 1974, The provisions of social relationships, in Z. Rubin (ed.), Doing
Unto Others (Prentice Hall, Englewood Cliffs), pp. 17–26.
WHOQoL Group: 1993, Study protocol for the World Health Organization project
to develop a quality of life assessment instrument (WHOQOL), Quality of Life
Research 2, pp. 153–159.
WHOQoL Group: 1996, WHOQOL-Bref: Introduction, Administration, Scoring
and Generic Version of the Assessment (World Health Organization, Geneva).
WHOQoL Group: 1998, Development of the World Health Organization WHO-
QOL-BREF Quality of Life Assessment. Psychological Medicine 28, pp. 551–558.
Williams, R., J. Barefoot, R. Califf, T. Haney, W. Saunders, D. Pryor
M. Hlatky, I. Siegler and D. Mark: 1992, Prognostic importance of social and
economic resources among medically treated patients with angiographically doc-
umented coronary artery disease, Journal of the American Medical Association
267, pp. 520–524.
548 GRAEME HAWTHORNE

Wu, M., R. Adams and M. Wilson: 2000, ACER Conquest: Generalised Item
Response Modelling Software (ACER press, Melbourne).
Yammarino, F., S. Skinner and T. Childers: 1991, Understanding mail survey re-
sponse behavior: a meta-analysis, Public Opinion Quarterly 55, pp. 613–639.

Australian Centre for Posttraumatic Mental Health

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