Can social support be translated into health? A missing link in clinical practice

B W K Lau 劉偉楷

HK Pract 2001;23:290-296

Summary

A link between social support (a psychological concept) and health (a medical core issue) has been assumed in clinical practice but it is less known how, how far, where and why it works. Various mechanisms have been postulated: for example, the effect mainly on blood clotting, cholesterol and sympathetic activity in heart disease; on immunological functioning and decisionmaking in cancer; on prenatal care and obstetric management in pregnancy; on health promotional behaviour and choice of lifestyle in preventable diseases, all of which are pertinent in the field of family medicine. However, social support is not always beneficial and it does have a negative impact on vulnerable individuals in certain circumstances. Clinical relevance is thus established but the methodological discourse on the construct is beyond the scope of the present article.

摘要

臨床實踐認為病人的社交情況與其健康有關，但 對有關機理所知甚少。目前有些理論探索有關的原因 和影響，例如：社會支援可以影響病人血液凝固情況， 影響膽固醇和交感神經的活動性，影響癌症患者的判 斷力和免疫功能，影響孕婦產前護理和產時冶療，影 響選擇個人生活模式和預防疾病的方式。這一切均切 合家庭醫學服務的範疇。社交支援對病人有益處但對 情緒脆弱的病人也可能帶來負面影響。因此，需要建 立臨床應用的準則。本文不討論具體的設立方法。

The relationship between social support and health

Over the past few decades, the relationship between social support and health has become a research focus it has been recognised that good social support, measured as being married, having frequent contacts with extended family and friends, and/or having involvement in religion, reduces mortality rates from all causes, and conversely, lack of social support has a detrimental effect on people’s health.¹ It is well known that most people develop and maintain a sense of well-being by involving themselves in a range of relationships in their lives that in toto satisfy these specific needs¹ and it appears that one of the factors believed to be involved in the likelihood of people becoming ill – either physically, mentally or both – is lack of support from other people. The way this has been conceived is in terms of the web of social relationships that ‘tie in’ a person to his or her community. Much research effort has since been invested in the examination of the beneficial effects of social support on health and well-being. To a large extent, research on social support and health is an outgrowth of research on life stress and social network.

It was then contended that social integration could have either a positive or a negative impact on health,² to be explained later. The connection between social support and wellness then becomes the subject of considerable debate, which has spawned hundreds of projects and studies on how social support or lack of it can affect health.

What is social support?

Social support has been defined in various ways. The term is generally used to refer to the individual belief that one is cared for and loved, esteemed and valued, and belongs to a network of communication and mutual obligation.³ In a practical sense, social support refers to various types of aid and succour provided by members of one’s social networks,⁴ of which emotional support involves providing empathy, care, love and trust; instrumental support consists of behaviours that directly help the person in need; and informational support involves providing people with information which they can use in coping with their problems.

Initially, it was defined according to the number of friends that were available to the individual. However, objective observations by others may not concur with subjective patient assessment, and instrumental support may have differing associations than emotional support. It would seem plausible that the number of social relationships a person has established is strongly related to the functional support the person perceives as available or actually receives.⁵ So this has been developed to include not only the number of friends supplying social support, but also the satisfaction with this support.⁶

In this context social support is often best understood as a person variable. Ultimately it is the individual’s personal construction, or perception, of support within their phenomic world which is most directly related to their behaviour and experience. Probably the perceived availability of social support may be more important than the actual social support received. Therefore, it appears that social support most clearly conforms to a person-in-context model, in that it is a function of both person and environment and of the interaction between the two.⁷

Healthy consequences of social support

There is now a great deal of evidence that on the one hand, individuals who lack social support from family, friends and the community have more symptoms of physical and psychological ill-health than those with support. On the other hand, the availability of social support is associated with a reduced risk of mental illness and physical illness, and even mortality.^2,8-10

In point of fact, studies have consistently shown the health of individuals with fewer social ties to be poorer. It seems that more socially isolated or less socially integrated individuals are even psychologically and physically less healthy and more likely to die.⁹ It was proposed that social isolation is a risk factor for death for both humans and animals.⁹ Using a sample of nearly seven thousand people, Berkman and Syme¹¹ found that the extra risk of death for the most isolated was between two and three times greater than for those individuals with most social contacts. Their meta-analysis supports the notion that positive health outcomes, especially longer life span, are associated with social support. Other prospective studies have also confirmed that social isolation is a risk factor of mortality and morbidity.^2,9 This is true for chronic^12,13 as well as acute¹⁴ illness. Horman¹⁵ broadens this perspective, taking a life cycle view of the relationship between social support and health. He concludes that social support at all phases of the life cycle has important health implications, and that health educators should encourage good quality relationships.

In terms of developmental stages, Jemmott and Magloire¹⁶ investigated the effect of social support on immunological functioning in a group of students going through the stress of final examinations. They found that students who reported stronger social support had higher levels of an antibody that plays a key role in warding off respiratory infections. Further, it would be interesting to know how a chronically abrasive marital relationship affects an individual’s immunity. In a longitudinal study Levenson and Gottman¹⁷ found that greater autonomic arousal among married couples strongly predicted later declines in marital satisfaction. At a 3-year follow-up, couples with greater declines in marital satisfaction had significantly poorer health ratings. If persistent physiological arousal occurs, as it frequently does in disturbed marital relationships, subsequent harmful changes can occur in immune function, leading to increased rates of infection and cancer.¹⁸ Recently, it has been shown that as an illustration of good social support, a good marriage, implying harmony and affection, does substantially decrease death rates from all causes, whereas chronic marital discord seems to lead to suppressed immunity and poor health.¹⁹

Positive correlations between high social support and greater immunological functioning were also demonstrated in another study, which focused on spouses of cancer patients.²⁰ A 20-year follow-up of breast cancer patients found that longevity was increased for those with strong social support, for example from support groups.²¹ Male cancer patients who were socially isolated and reported isolation were at poorer risk of survival. A good review is presented in the study of Uchino, Uno and Holt-Lunstad.²²

Several studies have shown social support related to lower rates for a particular type of morbidity: pregnancy or delivery complications. For example, an observational study by Collins et al²³ with a sample of 129 low-income women followed for six months showed that women with better quality support had better labour progress and their infants had higher Apgar scores; women with larger social networks had babies with higher birth weight. In a randomised trial in which Kennell et al²⁴ assigned a sample of 616 women to a supported group or two comparison groups, results indicated the supported group has shorter duration of labour, fewer cesarean sections for delivery, and fewer neonatal problems. Other evidence²⁵ also points to the fact that problems during pregnancy or birth complications are lower in women who have high levels of social support, again suggesting a link between social support and health status.

Interestingly, as keeping pet in company is a way of gaining a sense of support through attachment to another social animal, Siegel²⁶ found that elderly pet owners required less medical care than comparable subjects who did not own pets. In another study, women exposed to brief stress showed less physiological reaction when in the company of their pets.²⁷

The effect of social support on coronary heart disease

The most obvious of the positive effects of social support are the measurable differences in physiological responses to challenging or stressful situations. Gerin et al²⁸ found that there was greater cardiovascular reactivity among people who had no social support and who faced a challenge, especially compared to people who were supported by another individual. The people with no social support actually had higher blood pressure and faster heart rate. In general, poor social support and a sense of isolation put one at risk for coronary heart disease and increase the death rate from all causes.²⁹ More specifically a patient with coronary heart disease who is alone has a three-fold increase in mortality.³⁰ Relevant to the clinical practice is the finding of Kulik and Mahler³¹ that coronary bypass patients who were visited by spouses while in the hospital did not require as much pain medication nor remain in intensive care or hospital as long as patients who had relatively little spousal support during their hospital stay. Related to this, a more recent study³² has shown that being divorced or separated is an independent risk factor for myocardial infarction. House, Landis & Umberson⁹ showed that lack of social support adversely affects health as dramatically as does cigarette smoking or high cholesterol. In contrast, Vogt and associates³³ found that social networks may be more effective in supporting recovery from heart disease, strokes, hypertension and cancer than in preventing disease. Support groups benefit patients with coronary heart disease in a similar way.³⁴

The link between stress and social support

Another well-documented domain is the relationship between stress and social support. Greller et al³⁵ note that the most widely identified stress buffer is social support. They also point out that social support may affect stress in one of two ways – first, by acting as a compensation for strain, and second, by changing the experience of strain. Callaghan and Morrissey’s³⁶ review concludes that social support may play an important role in maintaining health while mitigating against the adverse effects of environmental and social stress. The Kobasa study³⁷ considers social support to be only one resource for lowering illness risk and contends that people with multiple resources are less likely to become ill, suggesting that social support explains relatively little about resistance to illness, but instead combines with hardiness and exercise during stressful times to decrease the likelihood of disease. A similar view is held by Cohen and Edwards,³⁸ who find that social support and other psychosocial assets buffer stress only after stress appraisal or reckoning. There was no indication that disease is prevented because of the presence of any psychosocial assets.

From the study of Hibbard and Pope³⁹ it was found that women who received social support at work had a lower mortality rate than non-employed women; furthermore, nonemployed women had an 80% greater risk of death than women who were contended with even lower levels of social support at work. Their findings also suggested that social support may be one aspect of employment that is protective of health. Falk and colleagues⁴⁰ also found that job strain was buffered by a positive social network and social support. The results from another study on East Germany refugees⁴¹ lend support to the relationship between stress from unemployment and health and suggest that this relationship is mediated (or modified positively) by social support. It follows that ill-health was greatest in those subjects who were both unemployed and who reported low social support. In addition, there is a suggestion that although social support may act as a mediating factor per se, it is itself also related to employment status, with individuals being able to gain social support from work colleagues. Moreover, Gore⁴² reports higher serum cholesterol levels, depression and illness among the unemployed who lack social support compared to those with supportive relationships.

In summary, there is evidence that depression, hostility, low socio-economic status, and jobs with high demand or little personal control are associated with low social support. It has been established that for people who are isolated, depressed or hostile, both the sympathetic nervous system (which governs early stress responses) and the hypothalamicpituitary- adrenocortical axis (which mediates long-term adjustments to stress) are more active than an average person. Common clinical sequelae are higher cholesterol levels, increased blood coagulability and compromised immune function. In particular, children from families of lower socioeconomic classes tend to grow up with experiences of negative communication at home and a hostile (or even violent) milieu outside home. Such adverse living conditions undoubtedly augment sympathetic activity which in turn could have lasting effect on neurotransmitters, especially serotonin. In the end, reduced serotonin can exacerbate all the risks for ill-health commonly found in lower socioeconomic groups in the community.

Negative impacts of social relationships

Though social support, by definition, is a positive influence in an individual’s life, social relationships are not necessarily positive. The latter may be negative or nonexistent, and as a result, may have very different impacts on health outcomes. Greller et al 35 argue that family and coworkers do not fundamentally change the effects of stressors, but may add or subtract from the experienced strain. Likewise, Shumaker and Hill⁴³ regard social networks (groups of contacts) as sources of social support for women as well as sources of added demands that could deplete their resources. By the same token, Auslander and Litwin⁴⁴ arrive at the conclusion that not all social networks are supportive, and some may even be sources of stress. Vinokur and van Ryn⁴⁵ further conceptualise social undermining (weakening) as a set of behaviours that negatively impact a target person, and empirically deduce that changes in mental health are much more highly associated with undermining than with social support. The effects of undermining are described as volatile and extreme while the effects of support are described as weaker but stable.

Again, social networks may impair motivation to continue health-related activities and so have a negative impact on the health of an individual in some cases. For example, Fleury⁴⁶ discovered that negative communication and conflicting values actually discourage patients from changing or make them question their ability to manage the necessary changes to maintain healthy lifestyles. Similarly, Evans and co-workers⁴⁷ found greater psychological distress and lower social support associated with increased residential density.

Not all social support is helpful. Ross and Mirowsky⁴⁸ identified from survey data that people who regularly use talking to others as a strategy for coping with stressful situations tended to be more depressed. In addition, there is evidence from the literature on chronic pain that those with more solicitous spouses tend to have more pain and be more depressed.⁴⁹

How may social support influence health?

If social support does influence or mediate the stressillness link, then what are the possible mechanisms? Two theories have been developed to explain the role of social support in health status:

According to the buffer hypothesis, social support helps individuals to cope with stress, thereby affecting health by protecting the individual against the negative impact of high levels of stress, and by improving his ability to cope with the stressor.⁶ This protective function is effective only or mainly when the person encounters a strong stressor (of high intensity or repulsive nature). Under low-stress conditions, little or no buffering occurs.⁵⁰ Then, how does buffering work? There are at least two ways.⁸ One way involves the process of cognitive appraisal or evaluation. When people encounter a strong stressor, those individuals with high levels of social support may be less likely to appraise the situation as stressful than those with low levels of support. Thus, those who are experiencing a crisis might be better able to cope if they know others who can give advice or even provide a solution to the problem.⁵ As a result, they judge that they can meet the demands and decide that the situation is not very stressful.⁵¹ The second way social support can buffer the effects of stress is by modifying people’s response to a stressor after they have appraised the situation as stressful. People with little social support are much less likely to have any advantages from what might be expected from having a support – so the negative impact of the stress is greater for them than for those with high levels of support.

According to the main effect hypothesis, social support itself is beneficial to health and well-being regardless of the amount of stress people experience and that the absence of social support is itself stressful. The beneficial effects of social support are similar under high and low stressor intensities. This suggests that social support mediates the stress-illness link, with its very presence reducing the effect of the stressor and its absence itself acting as a stressor.⁶

There are other ways by which beneficial effects may work.^8,52 People with high levels of social support may have a greater sense of belonging and self-esteem than those with little support. Indeed embeddness in a large interpersonal and social network may contribute positively to a social identity and self-esteem and a positive and stable self-esteem is important for individual well-being.⁵ The positive outlook this produces could be beneficial to health independently of stress experiences, such as by making individuals more resistant to infection.⁵⁰

There is some evidence that social support is positively associated with behaviours that are promotive of health¹¹ and that high levels of support may encourage people to lead more healthy lifestyles (with non-smoking and moderate drinking behaviour) than low social support does.⁵³ People with social support may feel, for example, that because others care about them and need them, they should exercise regularly, eat prudently, and sleep adequately. In the same vein, social support provides benefits by also modifying other risk factors, such as decreasing hypertension, acute and chronic potential stress, depression, and anxiety. For example, success in stopping smoking and the ability to maintain abstinence over a longer period of time have been linked to supportive behaviour from spouses and friends.²

Apart from practising effective health behaviours, people with high levels of support are more likely to seek medical attention before a problem becomes serious. They are also more likely to use health services, especially when the support network favours using those services,⁵⁴ and adhere to medical regimens.^31,54 As an example, social support may not only enable people to cope more successfully with stressful events, but also may influence stress-related behaviours that can function proactively to eliminate stressful events before they occur and/or to prevent a stressful event from intruding into other aspects of life. These functional aspects of social support may serve to contain a stressful event or to minimise its adverse health effects.

The Asian perspectives

Social support serves as a protective buffer for an individual during times of high stress, reducing the negative impact of stressful events and a common source of social support comes from his or her family. It was hypothesised by Indian researchers that the joint family system may provide a large supportive social network and counteract stress and its adverse effects.⁵⁵ To many, the joint family system is a traditional custom-bound, orthodox social structure with its own norms and authoritarian structure. It has certain benefits not only in terms of social security but costs in terms of social pressure and demands.

In Wu and Lam’s study⁵⁶ on adolescents’ hassles in Hong Kong, social support was correlated with general health status, as measured by the General Health Questionnaire. It seemed that its buffering influence between stress and health works at a more general level.⁵⁷

Perceived appraisal and perceived tangible support had a beneficial effect for those Chinese with a locus of external control (believing that the events or conditions of their lives are attributable to the action of others or forces outside themselves), irrespective of stress level. This group also exhibited a buffering pattern for perceived support. Hence, perceiving that these types of support are available if needed may be more instrumental in alleviating the effects of stress on adjustment than actually receiving support for Chinese. After all, it may be much easier and more feasible to build up a favourable perception than to actually receive support. Moreover, failure to enlist solid support naturally and promptly brings on frustration and, further, there is a negative side of receiving support: often self-esteem may be undermined as a result.

In spite of its obvious clinical importance, there is deploring scarcity, if any, of research on the effect of social support on health in the Asian region. In view of possible benefits to the illness course, extensive study in this respect is warranted to ascertain if it makes the same case with the extended family system that is prevalent in this part of the world.

Conclusion

Evidence that social support from significant others may enhance mental and physical health in a variety of populations is rapidly accumulating.^58,59 Several large prospective community studies found a strong correlation between lower mortality rates and intact social support systems. Social support has an effect on health habits as well as on health. It is postulated that social support may act to avert the onset of disease, to reduce severity of disease, or to enhance recovery from illness.⁶⁰ Several different mechanisms have been suggested and are coherent with existing physiological and psychological knowledge.² It is likely that understanding how the social environment influences these habits, embedding interventions in the social context, enlisting the cooperation of people who are important in the target individual’s life, and appealing to a person’s social responsibilities all help to promote successful health behavioural change.

This social support hypothesis is already leading to numerous clinical and community intervention programmes designed to increase the availability of social support to people under stress or otherwise at risk. The hope is that added social support will increase their coping capacities, reduce their need for professional help, limit periods of disability, and strengthen positive health-related behaviours. However, if a target person lacks requisite social skills or a receptivity to others, merely linking him to a supportive environment is not likely to succeed. Also, many of the interventions designed to change people’s negative health behaviours are targeted to the individual. Such an approach may have some degree of success in a culture that stresses independence; an approach that focuses more on the social network and the individual’s social environment may be more successful in collectively orientated culture such as the Chinese. Although this article has represented the plethora of research concerning the relationship between health and social support, there is a great need for appropriate research in the local context.

Key messages

1. Good social support in general reduces mortality from all causes and specifically from coronary heart disease, stroke and hypertension. It also reduces morbidity in viral infections, cancer, asthma, diabetes mellitis or pregnancy or delivery.
2. Social support influences health by protecting the individual against the negative impact of stress, improving his ability to cope with the stressor, speeding up recovery from acute illness episodes, promoting a greater sense of social identity and selfesteem, encouraging healthy lifestyles, and prompting health-seeking or help-seeking behaviours.
3. Its magnitude can be significant and prominent in some cases.
4. Social support is most beneficial in populations with special needs such as psychologically inadequate, chronically ill, old-aged persons, post-surgical patients and obstetric women, as well as those under constant stress such as life transitions, events or adversity.
5. Sometimes perceived support may work as well as actual support received.
6. However, social networks as sources of support may deplete one’s resources by adding demands, or discourage health-related activities through negative communications or conflicting values.