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1. Social Support And Recovery From Disease
Evidence examining the eﬀect of social support on recovery from illness comes from a variety of health areas. These include studies on infectious disease, as well as cancer, heart disease and other chronic illnesses. Under most circumstances, social support has been shown to moderate the negative eﬀects of illness and improve recovery. The eﬀect of social support, however, is dependent to a large degree on the characteristic of the illness and the match between the type of support oﬀered and the needs of the patient.
A recent study looked at the susceptibility to developing the common cold in volunteer subjects given nasal drops containing one or two cold viruses (Cohen et al. 1997). The results showed that those volunteers with more diverse social networks had a fourfold lower susceptibility to developing upper respiratory illness than those with a smaller number of social ties. In this study, social contact per se was not as important as the diversity of the individual’s social relationships. The more an individual had regular contact with a variety of social groups such as family, workmates, neighbors and other social networks, the more resistant he or she was to developing a cold. Another study examining the role of psychosocial factors on progression to AIDS, found stress and social support to be signiﬁcant predictors of HIV disease advancement (Leserman et al. 1999). In a follow-up period of ﬁve-and-a-half years, those participants who were more satisﬁed with the level of social support oﬀered by their friends and families at study entry were twice as likely to be free from AIDS than participants who were dissatisﬁed with their available level of social support.
As well as infectious diseases, social support has been shown to have a positive eﬀect on prognosis and recovery in a range of other medical conditions and illnesses. A study of low-income pregnant women found social support was associated with fewer complications during pregnancy and a higher infant birth weight. Research has found women who receive higher quality social support prior to delivery give birth to healthier babies and experience less post-partum depression. In chronic illnesses, Penninx et al. (1998) found positive eﬀects on depression for having a partner and having many close relationships, although the strength of the eﬀect diﬀered across illnesses. Other work has shown social support to be associated with lower levels of disability and depression in diabetics, and higher levels of compliance in patients on renal dialysis.
In the cardiovascular area, the eﬀect of having a close conﬁdant has been shown to have an important eﬀect on future mortality. Williams et al. (1992) followed 1,965 patients with coronary artery disease after angioplasty. After accounting for known medical prognostic factors such as cigarette smoking and family history of heart disease, the most important socio–economic variable in predicting time to death was the presence or absence of a spouse or conﬁdant. This ﬁnding is consistent with other studies of heart attack patients which have found a spouse to play a protective role in outcome.
A study of elderly myocardial infarction (MI) patients found those with low levels of social support were more likely to die in hospital and within six months of their heart attack even after controlling for severity of MI and other risk factors (Berkman et al. 1992). The available evidence suggests that the positive eﬀect of social support seems to be stronger for male than female MI patients. For example, a 10-year follow-up study of MI patients admitted to Baltimore hospitals found higher survival rates in married compared to unmarried patients. The positive eﬀect for marriage on both in-hospital and follow-up survival was stronger for males than females (Chandra et al. 1983).
Recent data suggest the more similar the spouse and patient view the illness the greater likelihood of eﬀective adjustment and recovery. In work with MI patients, beliefs about the cause of the heart attack were associated with positive changes in health behavior six months following MI. The belief by patients and spouse that the MI was caused by a faulty lifestyle was signiﬁcantly related to overall improvements in diet and to an increase in the frequency of strenuous exercise. Attributions about how the illness developed are very common following MI and show a high degree of agreement between patient and spouse. They provide important guideposts for patients and their spouses by directing coping towards controlling a future myocardial infarction. Patient and spousal beliefs that the MI was caused by a faulty lifestyle were precursors to making changes in the types of foods eaten at home and participation in regular exercise. However, the belief that the MI was caused by stress, which is the most common attribution made by patients, had no relationship with later lifestyle changes (Weinman et al. 2000).
A large number of studies have examined the eﬀect of social support on adjustment to cancer but fewer have studied the eﬀect of social support on mortality. The literature shows social support interventions to generally have a positive eﬀect on emotional adjustment to cancer. For example, a follow-up study of 294 people with breast, lung, or colorectal cancer found emotional support reduced distress and promoted adjustment to the disease (Ell et al. 1992). This study also found some survival beneﬁts for social support in women with localized breast cancer.
Some researchers have directly investigated the value of social support by using it in controlled trials with chronic illness populations. Two randomized trials seem to show some health beneﬁts for social support interventions. Spiegel et al. (1989) randomized women with metastatic breast cancer to participate in a one-year support group experience or usual care. There were no diﬀerences at four or eight months, but at one year the interventions group reported greater levels of adjustment than the control group. In a 10year follow-up, the researchers reported that the women who participated in the support group had a signiﬁcantly longer survival time. In another study of patients with Stage I and II malignant melanoma, patients were randomized to an intervention group that combined informational and education support or to a control condition. At six years, the intervention group showed decreased recurrence and increased survival six years later (Fawzy et al. 1993).
While these ﬁndings are encouraging for social support having health beneﬁts in some chronic illnesses, it is not clear from the research to date what part of the interventions are the most eﬀective or in which way they may inﬂuence health outcomes. It is still equivocal whether social support per se is the active ingredient that results in the positive outcome from these trials. As well as providing emotional support, the research interventions also provided education and information. Moreover, some later studies that have included social support interventions have not found the same eﬀect on health outcomes (e.g., Cunningham et al. 1998).
A popular and relatively recent source of social support for patients with chronic illness are informal support groups. Here, patients meet together to
discuss their condition and the diﬃculties and successes they have experienced in coping with their illness. As well as sharing personal illness experiences, these groups oﬀer the advantage of providing in- formation about utilizing health services, normalizing experiences and concerns and providing emotional support to group members. An analysis of social support groups found that the experience of physical illness was the most common reason for participation in such groups (Lieberman and Snowden 1993). Even after excluding substance abuse groups, this American survey found coping with physical illness made up 42 percent of the self-help group population. This study also suggested that these groups were more eﬀectively accessed by the middle class populations who often have good access to other support services. One limit of such social support groups is that participants have to be well enough to be physically able to attend meetings.
This pattern may be changing with the advent of the Internet. In the past ﬁve years there has been a dramatic increase in the use of the Internet in most Western households. This has been accompanied by an increasing number of discussion and support groups for chronic illness. Now without leaving home, chronic illness suﬀerers can read postings from other suﬀerers and participate in discussions about aspects of their condition. Recent research on these illness newsgroups suggests that certain diseases have a higher number of postings than others and these rates diﬀer markedly from their level of morbidity in the com- munity (Davidson and Pennebaker 1997). For example, patients with breast cancer and chronic fatigue syndrome have a high Internet usage, while postings from heart disease and prostate cancer patients are relatively under-represented. The value of Internet support groups for patients with chronic illness has yet to be evaluated but the use of this type of support is likely to rise markedly in the future.
2. Social Support And Recovery From Medical Procedures
Although not as extensively studied as recovery from illness, there is considerable evidence that social support also has a positive inﬂuence on recovery from hospitalization and medical procedures. In a large study of 40,820 patients admitted to a University Hospital in Ohio, researchers investigated the eﬀect of marital status on patient outcome (Gordon and Rosenthal 1995). They found that unmarried patients presented to hospital later than married patients. Unmarried surgical patients also had a higher risk of dying in hospital than married surgical patients, even after controlling for severity of illness, diagnosis and other demographic factors. Furthermore, unmarried patients tended to stay longer in hospital than married patients. The diﬀerences found in this study were greater in patients who had never married when compared with patients who were widowed, divorced, or separated. This study suggests that being unmarried and in particular, never having married, increases your risk of negative outcomes during hospitalization.
The eﬀect of diﬀerent types of social support on recovery has been examined in the context of coronary artery surgery. A study examining the eﬀect of diﬀerent types of social support on recovery following cardiac surgery found that the perceived availability of social support was related to emotional and functional outcomes up to a year following the operation. In particular, esteem support, or feedback that one is valued and respected by others, was consistently related to outcome over the follow-up period (King et al. 1993). It is not clear why esteem-related social support is associated with positive outcome, but it is likely that such support may give the individual in this situation greater resilience to setbacks and help instill more optimistic beliefs that they have the ability to recover from the surgery.
One fascinating aspect in the study of social support and recovery from medical procedures is the eﬀect of the patient’s hospital roommate on recovery. Research in this area demonstrates that whether a patient has a pre or postoperative roommate can inﬂuence outcome. Patients about to undergo surgery who are also assigned to a preoperative roommate show greater levels of anxiety and a slower recovery than those assigned a roommate who has already been through surgery. As well as lower levels of anxiety prior to surgery, being placed with a roommate who had been through surgery resulted in getting out of bed more quickly following the operation and a faster discharge from hospital (Kulik et al. 1993).
It seems likely then that the positive beneﬁts resulting from a postoperative roommate are partly due to the natural relief of seeing someone who has survived the same operation that the preoperative patient is about to undergo, and by normalizing the feelings and problems following the operation so these are less likely to be viewed as unusual or abnormal by the patient. Thus a roommate who has been through the operation or procedure can provide a practical role model for preparing patients for the post-operative pain, physical sensations and sequence of recovery following the operation.
Actions by others designed to aid or assist adjustment with medical problems is not always seen as helpful by the recipient. Negative reactions to intended helpful actions are actually quite common. One study of elderly chronic illness patients found half to receive support from their spouse they did not need and 28 percent reported not receiving assistance for a daily activity when needed. This mismatch between the need and provision of support has been the focus of study in the general social support area and is very relevant to the area of recovery from medical illness. Here, the evidence suggests that diﬀerent types of support are diﬀerentially valued depending on the relationship the provider has with the patient.
In an important study with cancer patients, Dakof and Taylor (1990) found emotional support was most likely to be valued when it came from intimate others, whereas informational support was more valued when it came from a physician or another cancer patient. This study found when there was a mismatch, such as when a patient needed emotional support from a spouse but received advice or information, then these actions were more likely to be seen as unhelpful. Unhelpful behaviors noted by patients were minimizing the problem, forced cheerfulness, medical care delivered without any emotional support, and being told not to worry. A later study using patients with the chronic non-life-threatening illnesses of irritable bowel syndrome and chronic headache, found these patients to put greater value on tangible and practical assistance and less on emotional support than the cancer patients in Dakof and Taylor’s sample (Martin et al. 1994).
These studies highlight how the characteristics of the illness may strongly inﬂuence the type of social support needed by patients. In some life-threatening conditions, where patients are frightened or daunted by the demand of treatment and prognosis, emotional needs are more prominent. In other illnesses, where the illness forms a major hurdle to be met on a more routine daily basis without the threat of disﬁgurement or death, then more practical issues such as assistance with childcare and transport become more valued.
A disparity in the intensity of social support can also cause diﬃculties for patients. Sometimes an aversion or fear of physical illness can cause family to avoid contact with the patient. While emotional support is the type of support most received by patients it is also the type of support likely to be perceived as most inadequate. However, overly intrusive oﬀers of assistance and help can also cause a negative reaction and increased stress. These ﬁndings highlight the importance of ﬁnding a balance between the needs of the patient and the type and level of social support.
The available evidence suggests social support has a positive inﬂuence on individuals’ susceptibility to infectious disease and recovery and adjustment to a variety of chronic illnesses. In the cardiac area there seem to be particularly strong beneﬁts for having a spouse or close conﬁdant and these eﬀects seem to be even stronger for men. Social support as an intervention in chronic illness seems to hold considerable promise but further trials are needed to conﬁrm early ﬁndings and to identify the necessary components of successful intervention programmes. With the rise of the Internet, electronic social support groups are going to provide an important source of information and peer support for patients with chronic illness.
There is strong evidence that the lack of social support is a risk factor for negative outcomes following hospitalization. Patients low in social support are more likely to present with more advanced illness and to be more likely to die while in hospital. However, it should be noted that many of the studies in the area are correlational, and the mechanisms that link social support to recovery from illness are still largely unknown. Recovery from surgery is an example where action by others that conveys to patients that they are respected and valued has a positive eﬀect on outcome. The type of roommate can also set up a more positive outcome from the operation by providing a constructive role model by minimizing catastrophizing and demonstrating eﬀective coping strategies.
A critical factor running through social support and the recovery from illness and medical procedures is the match between the needs of the patient and the type of social support provided. Diﬀerent types of illness and procedures cause diﬀering needs in terms of whether they require more emotional or tangible support. Emotional support is valued highest when it comes from a signiﬁcant other. A mismatch in the type or intensity of support can lead to diﬃculties and hamper overall recovery.
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