Social Support

Definition

Social support refers to the various types of support (i.e., assistance/help) that people receive from others and is generally classified into two (sometimes three) major categories: emotional, instrumental (and sometimes informational) support. Emotional support refers to the things that people do that make us feel loved and cared for, that bolster our sense of self-worth (e.g., talking over a problem, providing encouragement/positive feedback); such support frequently takes the form of non-tangible types of assistance. By contrast, instrumental support refers to the various types of tangible help that others may provide (e.g., help with childcare/housekeeping, provision of transportation or money). Informational support represents a third type of social support (one that is sometimes included within the instrumental support category) and refers to the help that others may offer through the provision of information.

Measurement

There are a variety of instruments currently used to assess social support; there is no single, "best" measure. This situation may be partially due to the fact that a wide range of different measurement strategies have yielded "scores" that have successfully been related to various health outcomes. Instruments range from single items used to assess whether or not major types of support (emotional, instrumental) are available ("yes/no")(Seeman & Berkman, 1988) to more extensive instruments which include multiple items asking about various types of emotional support and various types of instrumental/informational support (Seeman et al, 1994; Cohen et al, 1985; Schuster et al, 1990). These latter measures also vary with respect to the whether or not the items are asked regarding specific social relationships (e.g., types of support available from children versus friends; Seeman et al, 1994; Schuster et al, 1990) versus items asking more general about support available from "others" (Cohen et al, 1985). Psychometric data are available for the multiple item measures.

1. Mid-Mac Study Measures – Coefficient alphas of .83 - .91 for emotional support from spouse, family and friends indicate good internal reliability (data documentation from Mid-Mac).
2. MacArthur Successful Aging Study – Two-month test retest data indicate reasonable stability for measures of emotional support (.73) and for levels of demans/criticism (.80), and somewhat lower stability for instrumental support (.44 [.55 for rank correlation]) (Seeman et al, 1994).
3. Interpersonal Support Evaluation List – Test-retest data reveal correlations between .77-.86 and internal alpha estimates of .88-.90.

Choice of the appropriate measure(s) for use in research projects will likely be driven by such factors as: a) available time (some measures require considerably more time than others) and, b) whether assessments for different types of relationships are hypothesized to be important.

Relationship to SES

Social support has been found to vary positively with socio-economic status in studies in the US (Mid-Mac data, Matthews et al, 1989; Huang & Tausig, 1990; Campbell et al, 1986), England (Marmot et al, 1997) and Sweden (Ostergren, 1991). These patterns are seen for both emotional and instrumental support and for both men and women (though the differences appear to be somewhat greater for men; Marmot et al, 1997). Notably however, despite the evidence of statistically significant differences, the actual size of the observed variations is relatively small (e.g., r’s <.20, Mid-Mac data; maximum difference of 10% in the relative prevalence of low support across occupational grades, Marmot et al, 1997).

Research also suggests that social stressors that tend to be more prevalent in lower SES environments (e.g., residential crowding, fear of crime, financial strain) are associated with lower perceived support (Evans et al., 1989; Lepore et al, 1991a, b, c) and that these social stressors contribute to reductions in reported levels of social support because they tend to foster a distrust of others (Krause, 1992). However, there are also data indicating that high levels of support can be available within ethnic enclaves (e.g., Gans, 1962; Stack, 1977; MacLeod, 1995).

Relationship to Health

The strongest associations between social support (particularly emotional support) and a health outcome are seen in relation to psychological well-being. A large literature documents lower risk for depression and for psychological distress more generally for those who enjoy greater social support (for review see George, 1989 and most recently, e.g., Stansfeld et al, 1997). Relationships to physical health outcomes are less well documented. This may partly reflect the longer history of epidemiologic research using measures of social integration (i.e., network size) rather than social support (House et al, 1988; Seeman, 1996; see also Social Ties – Cohen notebook entry). To date, there is no evidence [to my knowledge] linking social support (as opposed to social integration) to incidence of major health outcomes such as MI, stroke or cancer. There is evidence linking both emotional and instrumental support to less extensive development of coronary atherosclerosis (Seeman & Syme, 1987, Blumenthal et al, 1987). The strongest evidence linking support to health is the research demonstrating better survival post-myocardial infarction for those with more emotional support (Berkman et al, 1992, Williams et al, 1992). Similar data indicate beneficial effects on prognosis post-stroke (Glass & Maddox, 1992). More generally, evidence suggests that emotional support is protective with respect to physical function (Seeman et al, 1995). The effects of instrumental support, however, appear considerably more mixed with higher levels of such support leading to greater disability in some cases (Seeman et al, 1996; for review, see also Burg & Seeman, 1994).

Data on health outcomes among children indicate that emotional support in particular impacts both psychological and physical health outcomes. Children exposed to deficit nurturing are at increased risk for depression (Kaslow et al, 1994, Leweinsohn et al, 1994) and suicidal ideation (Adams et al, 1994). Children born to mothers who lacked family support are at increased risk for low birth weight (Collins et al, 1993) and childhood exposure to less responsive parenting has been related to increased risk for childhood illness (Get ref to see actual outcomes: Gottman & Katz, 1989) and substance abuse among adolescents (Shedler & Block, 1990; Baumrind, 1991).

In addition to research on support and disease outcomes, there is a growing body of evidence linking social support to physiological regulatory processes. Among children, presence of a supportive caregiver has been shown to lower HPA to maternal separation reactivity (as indexed by salivary cortisol levels) (Gunnar et al, 1992). For adults, social support has likewise been found to predict lower levels of HPA and SNS activity in laboratory-based challenge paradigms as well as community settings (Seeman & McEwen, 1996). Evidence also links social support to lower risk of decline in CD4 counts among HIV infected men (Theorell et al, 1995). These data suggest that support may indeed play a role in the development of (or protection against) various disease outcomes. The generally weaker evidence linking support to health outcomes (as compared with associations seen for measures of social integration, social ties) may reflect the greater variability of support over time making it more difficult to predict the disease outcomes which are themselves the result of developmental processes.

Limitations

Social support measures suffer from two major limitations. One is the lack of established, ‘gold standard’ measures. The variety of different measures currently in use makes it difficult to draw conclusions based on comparisons of results across studies. The second limitation relates to the variability of support over time and our inability (to date) to assess these variations and their impact on relationships between social support and health outcomes. As a result, we currently have little evidence linking social support to the occurrence of major physical health outcomes, despite strong theoretical reasons for believing that such effects exist.

Network Usage

Measures of social support have been used extensively in research supported by various MacArthur Networks, including the current SES network (e.g., S. Cohen, T. Seeman), the Mid-Life Network (collaborative project Ryff & Seeman; R. Kessler), and the Successful Aging Network (Seeman et al, 1995; Seeman et al, 1994).