How does a health care administrator communicate with different audiences? What potential challenges might exist for health care administrators when engaged in commu

LlI /;j, 11 j) 'II ~ [F~ fli! , II L (;·1J' .1~

SOCIAL NETWORKS AND SOCIAL SUPPORT

Catherine A. Heaney

Barbara A. Israel

KEY POINTS

This chapter will

n Define functions and characteristics of social networks. n Provide a conceptual framework for understanding the relationship between social

networks and health. "' Briefly review the empirical support for this relationship. EJ List and describe types of social network interventions. n Present two examples of social network interventions for promoting health.

The powerful influence that social relationships have on health has garnered great interest among both researchers and practitioners. An understanding of the impact of social relationships on health status, health behaviors, and health decision making can contribute to the design of effective interventions for promoting health. Although no one theory adequately explicates the link between social relationships and health, various conceptual models and theories have guided research in this area.

DEFINITIONS AND TERMINOLOGY

Several key terms have been used in studies of the health-enhancing components of social relationships (Berkman, Glass, Brissette, and Seeman, 2000). The term social

190 Health Behavior and Health Education

integration has been used to refer to the existence of social ties. The term social network refers to the web of social relationships that surround individuals. The pro­ vision of social support is one of the important functions of social relationships. Thus, the term social network refers to linkages between people that may or may not pro­ vide social support and that may serve functions other than providing support. More recently, the term social capital has been used to describe certain resources and norms that arise from social networks (Ferlander, 2007).

The structure of social networks can be described in terms of dyadic character­ istics (that is, characteristics of specific relationships between the focal individual and other people in the network) and in terms of characteristics of the network as a whole (Israel, 1982; House, Umberson, and Landis, 1988). Examples of dyadic char­ acteristics include the extent to which resources and support are both given and re­ ceived in a relationship (reciprocity), the extent to which a relationship is characterized by emotional closeness (intensity or strength), the extent to which a relationship is embedded in a formal organizational or institutional structure (formality), and the ex­ tent to which a relationship serves a variety of functions (complexity). Examples of characteristics that describe a whole network include the extent to which network 1nembers are silnilar in tenns of demographic characteristics such as age, race, and socioeconomic status (homogeneity); the extent to which network members live in close proximity to the focal person (geographic dispersion), and the extent to which network members know and interact with each other (density).

Social networks give rise to various social functions: social influence, social con­ trol, social undermining, social comparison, companionship, and social support. This chapter focuses on social networks and the provision of social support. The term so­ cial support has been defined and measured in numerous ways. According to semi­ nal work by House (1981), social support is the functional content of relationships that can be categorized into four broad types of supportive behaviors or acts:

I. Emotional support involves the provision of empathy, love, trust, and caring.

2. Instrumental support involves the provision of tangible aid and services that directly assist a person in need.

3. Informational support is the provision of advice, suggestions, and information that a person can use to address problems.

4. Appraisal support involves the provision of information that is useful for self­ evaluation purposes-in other words, constructive feedback and affirmation.

Although these four types of support can be differentiated conceptually, relation­ ships that provide one type often also provide other types, thus making it difficult to study them empirically as separate constructs. (For a comprehensive review of meas­ urement and methodological issues, see Barrera, 2000; Cohen, Underwood, and Got­ tlieb, 2000.) Table 9.1 summarizes the key concepts and their definitions.

Social support can be distinguished from other functions of social relationships (Burg and Seeman, 1994). Social support is always intended (by the provider of the support) to be helpful, thus distinguishing it from intentional negative interactions (for example, social undermining behaviors such as angry criticism and hassling).

Social Networks and Social Support 191

Characteristics and Functions of Social Networks.

Concepts Definitions

Structural characteristics of social networks:

Reciprocity Extent to which resources and support are both given and received in a relationship

Intensity or Extent to which social relationships offer emotional closeness strength

Complexity Extent to which social relationships serve many functions

Formality Extent to which social relationships exist in the context of organizational or institutional roles

Density Extent to which network members know and interact with each other

Homogeneity Extent to which network members are demographically similar

Geographic Extent to which network members live in close proximity to focal dispersion person

Directionality Extent to which members of the dyad share equal power and influence

Functions of social networks:

Social capital Resources characterized by norms of reciprocity and social trust

Social influence Process by which thoughts and actions are changed by actions of others

Social undermining Process by which others express negative affect or criticism or hinder one's attainment of goals

Companionship Sharing leisure or other activities with network members

Social support Aid and assistance exchanged through social relationships and interpersonal transactions

Types of social support:

Emotional support Expressions of empathy, love, trust, and caring

Instrumental support Tangible.aid and services

Informational support Advice, suggestions, and information

Appraisal support Information that is useful for selfcevaluation

192 Health Behavior and Health Education

Whether or not the intended support is perceived or experienced as helpful by there­ ceiver is an empirical question, and indeed, negative perceptions and consequences of well-intended interpersonal exchanges have been identified (for example, Wort­ man and Lehman, 1985). In addition, social support is consciously provided, which sets it apart from the social influence exerted through simple observation of the be­ havior of others (Bandnra, 1986) or from receiver-initiated social comparison processes (Wood, 1996). Finally, although the provision of social support, particularly infor­ mational support, can attempt to influence the thoughts and behaviors of the receiver, such informational support is provided in an interpersonal context of caring, trust, and respect for each person's right to make his or her own choices. This quality dis­ tinguishes social support from some other types of social influence that derive from the ability to provide or withhold desired resources or approval.

Although many investigations of the effects of social relationships on health have narrowly focused on the provision of social support, a broader social network approach has several advantages. First, a social network approach can incorporate functions or characteristics of social relationships other than social support (Israel, 1982; Berkman and Glass, 2000). For example, there is increasing evidence that negative interpersonal interactions, such as those characterized by mistrust, hassles, criticism, and domina­ tion, are more strongly related to snch factors as negative mood (Fleishman and oth­ ers, 2000), depression (Cranford, 2004), risky health behaviors such as substance abuse (Oetzel, Duran, Jiang, and Lucero, 2007), and susceptibility to infectious disease (Cohen and others, 1997) than is a lack of social support. Second, whereas a social support approach usually focuses on one relationship at a time, a social network ap­ proach allows for the study of how changes in one social relationship affect other re­ lationships. Third, a social network approach facilitates the investigation of how structural network characteristics influence the quantity and quality of social support that are exchanged (McLeroy, Gottlieb, and Heaney, 200 1). This information can be important for the development of effective support-enhancing interventions.

BACKGROUND OF THE CONCEPTS

Barnes's (1954) pioneering work in a Norwegian village first presented the concept of a social network to describe patterns of social relationships that were not easily explained by more traditional social units such as extended families or work groups. Much of the early work on social networks was exploratory and descriptive. The find­ ings from these studies provided a knowledge base that helped identify network char­ acteristics. In general, it was found that close-knit networks exchange more affective and instrumental support, and also exert more social influence on members to con­ form to network norms. Homogenous networks, networks with more reciprocal link­ ages, and networks with closer geographical proximity were also more effective in providing affective and instrumental support (see Israel, 1982; Berkman and Glass, 2000 for reviews).

The study of social support owes much to the work of social epidemiologist John Cassel (1976). Drawing from numerous animal and human studies, Cassel posited

Social Networks and Social Support 193

that social support served as a key psychosocial "protective" factor that reduced in­ dividuals' vulnerability to the deleterious effects of stress on health. He also speci­ fied that psychosocial factors such as social support were likely to play a nonspecific role in the etiology of disease. Thus, social support may influence the incidence and prevalence of a wide array of health outcomes.

From the previous discussion, it is clear that the terms social network and so­ cial support do not connote theories per se. Rather, they are concepts that describe the structure, processes, and functions of social relationships. Various sociological and social psychological theories (such as exchange theory, attachment theory, and symbolic interactionism) have been used to explain the basic interpersonal processes that underlie the association between social relationships and health (Berkman, Glass, Brissette, and Seeman, 2000).

RELATIONSHIP OF SOCIAL NETWORKS AND SOCIAL SUPPORT TO HEALTH

The mechanisms through which social networks and social support may have positive effects on physical, mental, and social health are summarized in Figure 9.1. The model depicts social networks and social support as the starting point or initiator of a causal flow toward health outcomes. In actuality, many of the relationships in Figure 9.1 en­ tail reciprocal influence; for example, health status will influence the extent to which one is able to maintain and mobilize a social network.

In Figure 9.1, Pathway I represents a hypothesized direct effect of social net­ works and social support on health. By meeting basic human needs for companion­ ship, intimacy, a sense of belonging, and reassurance of one's worth as a person, supportive ties may enhance well-being and health, regardless of stress levels (Berk­ man and Glass, 2000). Pathways 2 and 4 represent a hypothesized effect of social net­ works and social support on individual coping resources and community resources, respectively. For example, social networks and social support can enhance an indi­ vidual's ability to access new contacts and information and to identify and solve prob­ lems. If the support provided helps to reduce uncertainty and unpredictability or helps to produce desired outcomes, then a sense of personal control over specific situations and life domains will be enhanced. In addition, the theory of symbolic interaction­ ism suggests that human behavior is based on the meaning that people assign to events. This meaning is derived, in large part, from their social interactions (Israel, 1982; Berkman, Glass, Brissette, and Seeman, 2000). Thus, people's social network link­ ages may help them reinterpret events or problems in a more positive and construc­ tive light (Thoits, 1995).

The potential effects of social networks and social support on organizational and community competence are less well studied. However, strengthening social networks and enhancing the exchange of social support may increase a community's ability to garner its resources and solve problems. Several community-level interventions have shown how intentional network building and the strengthening of social support within communities are associated with enhanced community capacity and control (Minkler,

1 5 Social Networks

and Social Support I 2 4

3

IStressors I

Individual Coping Organizational Resources and Community

• Problem-solving Resources abilities 2a 4a • Community——4-­ -+—-­

• Access to new empowerment contacts and • Community information competence

• Perceived control

Health Behaviors

• Behavioral risk factors

and Social Health '""'"'· "'""'· l__j • Preventive health

practices

• Illness behaviors

194 Health Behavior and Health Education

~;~GUt{[ ~), '~, Conceptual Model for the Relationship of Social Networks and Social Support to Health.

2001; Eng and Parker, 1994). Indeed, these are strategies for building social capital­ investing in social relationships so that generalized social trust and norms of reci­ procity are strengthened within the community (Ferlander, 2007).

Resources at both the individual and community levels may have direct health­ enhancing effects and may also diminish the negative effects on health due to expo­ sure to stressors. When people experience stressors, having enhanced individual or community resources increases the likelihood that stressors will be handled or coped with in a way that reduces both short-term and long-term adverse health consequences. This effect is called a "buffering effect" and is reflected in Pathways 2a aud 4a. Re­ search involving people going through major life transitions (such as loss of a job or birth of a child) has shown how social networks and social support influence the cop­ ing process and buffer the effects of the stressor on health (see, for example, Hod­ nett, Gates, Hofmeyr, and Sakala, 2007).

Pathway 3 suggests that social networks and social support may influence the fre­ quency and duration of exposure to stressors. For example, a supportive supervisor

Social Networks and Social Support 195

may ensure that an employee is not given more work to do than can be completed in the available time. Similarly, having a social network that provides information about new jobs may reduce the likelihood that a person will suffer from long-term unem­ ployment. Reduced exposure to stressors is then, in turn, associated with enhanced mental and physical health.

Pathway 5 reflects the potential effects of social networks and social snpport on health behaviors. Through tbe interpersonal exchanges within a social network, in­ dividuals are influenced and supported in such health behaviors as adherence to med­ ical regimens (DiMatteo, 2004), help-seeking behavior (McKinlay, 1980; Starrett and others, 1990), smoking cessation (Palmer, Baucom, and McBride, 2000), and weight loss (Wing and Jeffery, 1999). Through influences on preventive health behavior, ill­ ness behavior, and sick-role behavior, Pathway 5 makes explicit that social networks and social support may affect the incidence of and recovery from disease.

EMPIRICAL EVIDENCE ON THE INFLUENCE OF SOCIAL RELATIONSHIPS

Numerous reviews of the empirical studies address the influence of social relation­ ships on health (see, for example, Barrera, 2000; Berkman and Glass, 2000; Uchino, 2004). Although there are some inconsistencies in this body of research, few today would disagree with House's summary statement made two decades ago: "Although the results of individual studies are usually open to alternative interpretations, the patterns of results across the full range of studies strongly suggests that what are var­ iously termed social relationships, social networks, and social support have impor­ tant causal effects on health, exposure to stress, and the relationship between stress and health" (House, 1987).

Prospective epidemiological studies, most often using measures of social inte­ gration, consistently find a relationship between a lack of social relationships and all­ cause mortality (Berkman and Glass, 2000). More recently, a number of studies documented that intimate ties and the emotional support provided by them increase survival rates among people with severe cardiovascular disease (Berkman and Glass, 2000). Evidence for buffering effects is less conclusive, but studies do suggest that social support mobilized to help a person cope with a stressor reduces the negative effects of the stressor on health (Cohen and Wills, 1985; Thoits, 1995). Although the direct effects and the buffering effects of social networks and social support were ini­ tially investigated as either-or relationships, evidence suggests that social support and social networks have both types of effects, and that the predominance of one effect over the other depends on the target population, the situation being studied, and the ways in which the social relationship concept is measured (Cohen and Wills, 1985; House, Umberson, and Landis, 1988; Krause, 1995; Thoits, 1995).

The effect of social relationships on all-cause mortality supports the hypothesis, first put forth by Cassel (1976), that the effect of social relationships on health is not specific to any one disease process. This nonspecific role may explain why studies of the effect of social relationships on specific morbidities have not been conclusive

196 Health Behavior and Health Education

(House, Umbersou, and Landis, 1988; Berkman and Glass, 2000), As our understand­ ing of the influence of social support on the cardiovascular, neuroendocrine, and immune systems deepens (Uchino, 2006), we may be able to make better sense of the pattern of results. Although evidence for a link between social networks and social support and the incidence of particular diseases is inconsistent (Vogt and others, 1992), a positive role for affective support in the processes of coping with and recovering from serious illness has been consistently documented (Spiegel and Diamond, 2001; Wang, Mittleman, and Orth-Gomer, 2005).

The association between social relationships and health does not follow a linear dose-response curve. Rather, very low levels of social integration (that is, having no strong social ties) are most deleterious, with higher levels being less advantageous once a threshold level has been reached (Honse, 2001). Having at least one strong intimate relationship is an important predictor of good health (Michael, Colditz, Coakley, and Kawachi, 1999). For example, in a study of African American elderly women, severe social isolation (that is, living alone and not having had contact with family or friends during the last two weeks) was associated with a three-fold increase in mortality dur­ ing a five-year follow-up period (LaVeist, Sellers, Brown, and Nickerson, 1997).

The influence of social network characteristics on social support, health behav­ ior, and health status has been less thoroughly examined than has the relationship be­ tween social support and health (Berkman and Glass, 2000). However, the results of earlier reviews of the literature suggest that the social network's reciprocity and in­ tensity were somewhat consistently linked to positive mental health (Israel, 1982; House, Umberson, and Landis, 1988). In addition, networks that were characterized by few ties, high-intensity relationships, high density, and close geographical prox­ imity maintained social identity and the exchange of affective support. Thus, these networks were most health-enhancing when these social network functions were needed. However, during times of transition and change, networks that are larger, more diffuse, and composed of less intense ties may be more adaptive because they are better at facilitating social outreach and exchanging new information (Granovet­ ter, 1983). Furthermore, more recent studies provide evidence that the size and den­ sity of social networks that endorse risk-taking norms are associated with higher levels of risk-taking behaviors, such as injection drug use (Berkman and Glass, 2000).

Demographically defined subgroups maintain qualitatively different social net­ works and experience health benefits from those networks (House, Umberson, and Landis, 1988). Shumaker and Hill (1991) reviewed gender differences in the link be­ tween social support and physical health. They suggested that prospective epidemio­ logical studies investigating the effect of social relationships on mortality found a weaker health-protective effect for women than for men. In addition, women of a particular age group (usually over fifty years of age) experienced a positive association between high levels of social support and mortality. Noting that women tend to cast a "wider net of concern" (that is, maintain more strong ties), are more likely to be both the providers and recipients of social support, and are more responsive to the life events of others than are men, the authors suggest that further study is needed to explore the impact of these differences on the health-protective potential of women's social networks.

Social Networks and Social Support 197

TRANSLATING THEORY AND RESEARCH INTO PRACTICE

Social epidemiological studies have clearly documented the beneficial effects ou health of supportive social networks. However, these observational studies cannot tell us whether we can promote good health by strengthening social networks and increas­ ing the availability of social support. Intervention research is needed to identify the most potent causal agents and critical time periods for social network enhancement. Health education and health behavior researchers who develop and implement social network enhancement interventions face several decision points. Honse (1981) sum­ marized these decision points in a single question: In order to effectively enhance the health-protective functions of social networks, who should provide what to whom (and when)? The issues of who, what, and when are discussed next.

Who

Social support can be provided by many types of people, both in one's informal net­ work (for example, family, friends, coworkers, supervisors) and in more formal help­ ing networks (for example, health care professionals, human service workers). Different network members are likely to provide differing amounts and types of support (McLeroy, Gottlieb, and Heaney, 2001 ). In addition, the effectiveness of the support provided may depend on the source of the support (Agneessens, Waege, and Lievens, 2006). For ex­ ample, long-term assistance is most often provided by family members; neighbors and friends are more likely to provide short-term aid (McLeroy, Gottlieb, and Heaney, 2001). In medical care settings, patients often need emotional support from family and friends and informational support from health care professionals (Blanchard and others, 1995).

Thoits offered a more comprehensive approach to defining an effective source of support: the effective provision of support is likely to stem from people who are so­ cially similar to the support recipients and who have experienced similar stressors or situations (Thoits, 1995). These characteristics enhance the "empathic understand­ ing" of the support provider, making it more likely that the support proffered is in concert with the needs and values of the recipient. In addition, the person who de­ sires the support is more likely to overcome the stigma attached to needing help and to seek or mobilize support when the social network member is perceived to be em­ pathic and understanding. Empathic understanding is particularly relevant to the ex­ change of emotional support but also applies to instrumental and informational support.

Long-standing, intimate social network ties have unique capabilities to provide social support (Gottlieb and Wagner, 1991; Feeney and Collins, 2003). However, there can be a down side to depending on these types of relationships for support, partic­ ularly informational support. Gottlieb and Wagner (1991) noted that people in close relationships are often distressed by the same stressor and that the nature and qual­ ity of the support provided is affected by the distress levels of the helper. Also, be­ cause the support providers are very interested in the well-being of the support recipients, when support attempts are not well received or do not result in positive changes in the receiver, the helpers can react negatively (Feeney and Collins, 2003).

198 Health Behavior and Health Education

This is most likely to occur wheu information or advice is provided. Intimate ties may be best used for emotional support, but other relationships may be better suited for informational support (Gottlieb, 2000).

Considerable debate has focused on whether professional helpers are effective sources of social support. Health education interventions may attempt to enhance the social support available to participants by linking them with professional helpers. Professional helpers often have access to information and resources that are not oth­ erwise available in the social network. However, professional helpers are rarely avail­ able to provide social support over long periods of time. Additionally, professional, lay relationships are not typically reciprocal and may involve large power differen­ tials or lack the "empathic understanding" described earlier. Health educators have attempted to overcome these limitations of professional helpers by recruiting mem­ bers of the community and training them in the knowledge and skills needed to ad­ dress the target health issue (for example, screening mammography or asthma self-management). These lay health advisers or community health workers can then provide the needed informational support while maintaining their "empathic under­ standing," gained through life experiences similar to those of recipients (Friedman and others, 2006). In other interventions, professional and informal helpers are inte­ grated into a problem-defined support system created to address specific health is­ sues, such as recovery from stroke (Glass and others, 2000).

What

The perceptions of support recipients, rather than the objective behaviors involved in interactions, are most strongly linked to recipients' health and well-being (Wething­ ton and Kessler, 1986). Although the perceptions of support recipients are certainly correlated with objective behaviors, this correlation is modest, and it is necessary to identify factors that may influence whether behaviors are perceived as supportive (Haber, Cohen, Lucas, and Baltes, 2007). These factors include the recipient's pre­ vious experiences of support with the helper and the social context of the relation­ ship (for example, are the two people in competition for resources? Does one have the power to reward or punish the other?). Other factors are role expectations and in­ dividual preferences for types and amounts of social support.

Given the multiple factors that affect how social interactions are perceived, a pri­ ori assumptions about which specific behaviors increase perceived social support may be ill-advised. Ways in which social network members can be more supportive can be best identified through involvement of the intended intervention participants. Dis­ cussion among the interested parties could include previous successful support ef­ forts and support efforts that have gone awry; such discussion could also generate a set of desired social behaviors and skills specific to the population and problem being addressed. For example, a program designed to enhance coworker and supervisor sup­ port used a group format in which employees gleaned suggestions on ways to mod­ ify their behavior from the stories of other employees' effective, supportive social interactions (Heaney, 1991). Similar strategies have been used in smoking cessation

Social Networks and Social Support 199

interventions that attempted to enhance the support for cessation provided by sig­ nific

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.