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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 nificant others (Palmer, Baucom, and McBride, 2000),

When

Research has suggested that the types of social networks and social support that ef­ fectively enhance well-being and health differ according to the age or developmen­ tal stage of the support recipient (Kahn and Antonucci, 1980). In addition, people who are experiencing a major life transition or stressor benefit from different types of support during the various stages of coping with the stressor (Thoits, 1995). For example, someone whose spouse has just died may benefit from a closely knit, dense social network that provides strong affective support to the bereaved. However, as the widowed individual makes life modifications to adapt to the loss, more diffuse net­ works that offer access to new social ties and diverse informational support may be most helpful.

SOCIAL NETWORK AND SOCIAL SUPPORT INTERVENTIONS

Several typologies of social network and social support interventions have been sug­ gested (Israel, 1982; McLeroy, Gottlieb, and Heaney, 2001; Gottlieb, 2000). Table 9.2 presents four categories of interventions: (I) enhancing existing social network link­ ages, (2) developing new social network linkages, (3) enhancing networks through the use of indigenous natural helpers, and (4) enhancing networks at the community level through participatory problem-solving processes. A fifth category is composed of in­ terventions that use a combination of these types of interventions. Interventions in these five categories are briefly described next, highlighting the challenges and poten­ tial benefits of each type. The quantity and quality of the research investigating the ef­ fectiveness of social network interventions differs across the types of intervention. Further research is needed to assess the efficacy of the various interventions and the conditions under which each of the types of interventions is most likely to be effective.

Enhancing Existing Network Ties

Existing network ties often offer much untapped potential. Interventions aimed at en­ hancing existing ties attempt to change the attitudes and behaviors of the support recip­ ient, the support provider, or both. The transactional nature of social exchanges suggests that the last may be most effective, and some research is consistent with this sugges­ tion (Heaney, 1991).

Interventions to enhance existing relationships often include activities to build skills for effective support mobilization, provision, and receipt. They may focus on enhancing the quality of social ties in order to address specific health issues or to pro­ vide support across many different situations. For example, cardiac patients were counseled on how to strengthen their social networks, in order to enhance their abil­ ity to cope with their illness (ENRICHD Investigators, 200 I; see further description

200 Health Behavior and Health Education

Tf< "'" ,~: H :t•:n.JL .::: ')) ·''"'"·· I f Typo ogy o Socia I kNetwor Interventions.

Intervention Type

Enhancing existing net­ work linkages

Developing new social network linkages

Enhancing networks through the use of indige­ nous natural helpers and community health workers (CHWs)

Enhancing networks through community capacity building and problem solving

Source: Adapted from Israel, 1982.

Examples of Intervention Activities

Training of network mem­ bers in skills for providing support

Training of focal individual in mobilizing and main­ taining social networks

Systems approach (for ex­ ample. marital counseling or family therapy)

Creating linkages to mentors

Developing buddy systems

Facilitating self-help groups

Identification of natural helpers or CHWs

Analysis of natural helpers" existing social networks

Training in health topics and community problem­ solving strategies

Identification of overlap­ ping networks within the community

Examination of social net­ work characteristics of members of the selected need or target area

Facilitation of ongoing community problem iden­ tification and problem solving

Selected References

Heaney, 1991

Sandler and others, 1992

Wing and Jeffery, 1999

Palmer, Baucom, and McBride, 2000

Helgeson and Gottlieb, 2000

Chesler and Chesney, 1995

Rhodes, 2002

Eng and Hatch, 1991

Kegler and Malcoe, 2004

Earp and others, 1997

McQuiston and Flaskerud, 2003

Krieger, Takaro, Song, and Weaver, 2005

Minkler, 2001

Boutilier, Cleverly, and Labonte, 2000

Social Networks and Social Support 201

later in this chapter.) Partners or significant others were incorporated into smoking cessation programs (Palmer, Baucom, and McBride, 2000) and weight loss programs (Wing and Jeffery, 1999) to provide support for behavior change.

Some of the challenges with this type of intervention include identifying exist­ ing network members who are committed to providing support and have the resources to sustain the commitment; identifying the changes in attitudes and behaviors that will result in increased perceived support on the part of the support recipient; and in­ tervening in ways that are consistent with established norms and styles of interaction.

Developing New Social Network Linkages

Interventions designed to develop new social network linkages are most useful when the existing network is small, overburdened, or unable to provide effective support. Sometimes new ties are introduced to alleviate chronic social isolation, such as that experienced by the elderly (Heller and others, 1991). Most ofteu new ties are intro­ duced in response to a major life transition or specific stressor. In these cases, the ex­ isting network may lack the requisite experiential or specialized knowledge about the specific stressor.

Some interventions introduce "mentors" or "advisers"-people who have already coped with the situation being experienced by the focal individual (Eckenrode and Hamilton, 2000; Rhodes, 2002). Other interventions introduce "buddies" who are ex­ periencing the stressor or life transition at the same time as the focal person. For example, in some smoking cessation programs and weight control programs, partic­ ipants are encouraged to "buddy np" with another participant to provide support and encouragement to each other (Palmer, Baucom, and McBride, 2000).

Self-help or mutual aid groups provide a new set of network ties. Usually, peo­ ple come together in self-help groups because they are facing a common stressor or because they want to bring about similar changes, either at the individual level (for example, individual weight loss) or at a community level (for example, increased ac­ cess to health care in one's community). In self-help or mutual aid groups, the roles of support provider and support recipient are mutually shared among the members. Thus, the ties often entail high levels of reciprocity. Such groups can be particularly effective for participants who cannot mobilize social support from their other social relationships. Although a full description of self-help groups is beyond the scope of this chapter, several good reviews and descriptions exist (see Chesler and Chesney, 1995, and Helgeson and Gottlieb, 2000). Recently, Internet-based support groups have gained in popularity. People with common interests join a virtual community to share experiences and exchange support. Although there is little evidence of their ef­ fectiveness to date (Eysenbach and others, 2004), they are likely to be a continuing trend in how people seek information and support for specific life transitions and health problems. Research is needed to identify important components of Internet support groups, and for whom and under what circumstances they can have health­ promoting effects.

202 Health Behavior and Health Education

Use of Indigenous Natural Helpers and Community Health Workers

Natural helpers are members of social networks to whom other network members nat­ urally turn for advice, support, and other types of aid (Israel, 1985). They are re­ spected and trusted network members who are responsive to the needs of others. In addition to providing support directly to network members, natural helpers can link social network members to each other and to resources outside the network. Commu­ nity health workers (CHWs) are members of the community being served, who are recmited to provide frontline health services and outreach. CHWs are often employed by the health care system to provide a linkage between the community members and formal health services (Love, Gardner, and Legion, 1997).

One of the first tasks in natural helper interventions is to identify the people who currently fill these helping roles. Although various strategies have been used to do this (Eng and Young, 1992), commonly people in the community are asked for the names of people who demonstrate the characteristics of natural helpers. The partic­ ipation of community members in the identification process is critical. People whose names are repeatedly mentioned can be contacted aud recruited. Once the natural helpers are recruited, the health professional can provide the needed information on specific health topics, health and human service resources available in the commu­ nity, and community problem-solving strategies, and can engage in a consultative re­ lationship with the natural helpers.

Natural helper interventions have been conducted in a number of different com­ munities, including urban neighborhoods, rural counties, Native American commu­ nities, migrant farmworker streams, and church congregations (Kegler and Malcoe, 2004; McQuiston and Flaskerud, 2003; Eng and Hatch, 1991). CHWs have also been employed in many different settings (Love, Gardner, and Legion, 1997; Schulz and others, 2002; Krieger and others, 2002).

Enhancing Networks Through Community Capacity Building and Problem Solving

Interventions that involve community members in identifying and resolving commu­ nity problems may indirectly strengthen the social networks that exist in the community. Such interventions (see, for example, Boutilier, Cleverly, and Labonte, 2000; Roth­ man, Erlich, and Tropman, 2001) use community organizing techniques with the goals of (I) enhancing the capacity of a community to resolve its problems, (2) increasing the community's role in making decisions that have important implications for com­ munity life, and (3) resolving specific problems. Through participating in coiiective problem-solving processes, community members forge new network ties and strengthen existing ones. For example, in the Tenderloin Senior Outreach Project, elderly resi­ dents in the Tenderloin district of San Francisco formed groups and coalitions to ad­ dress safety and health concerns. Through participation in these groups, the residents became less socially isolated and began to turn to each other for information, advice, and support (Minkler, 2001). See Chapter Thirteen for an extended analysis of com­ munity organizing and capacity development.

Social Networks and Social Support 203

Although community problem-solving interventions indirectly affect social net­ works, social network strategies could be incorporated into both the assessment and implementation stages of these interventions (Israel, I 985). The community assess­ ment could determine how people gain information, resources, and support, as well as identify potential problem areas. Examining the extent to which people's networks overlap may aid in the diffusion of new information throughout the community.

Combining Strategies

Some programs have combined the intervention strategies described earlier to max­ imize the impact of the program. For example, a program that enhances existing net­ work ties and also forges new ties can benefit from well-established social relationships and the infusion of new social resources. In the Family Bereavement Program (San­ dler and others, 1992), members of families that had experienced a loss attended work­ shops, during which they explored ways family members could provide support to each other. During the workshops, the participants also engaged in supportive inter­ actions with other bereaved families. After participating in the workshops, each fam­ ily was matched with a family adviser, who then provided ongoing emotional and informational support, shoring up overburdened family sources of support.

Combining natural helper interventions with community problem solving is an­ other potentially effective strategy (Eng and Hatch, 1991; Schulz and others, 2002). Although natural helpers can address the needs of the individual network members, the community-level strategy can address some of the broader social, legal, and economic problems facing the community. This results in a more comprehensive eco­ logical approach to enhancing the health of the community. Lay health advisers may be able to enhance the effectiveness of community-level problem solving by integrating community residents more fully into the life of the community and, more specifically, into cooperative problem-solving efforts. Future research is needed to evaluate the efficacy of combining these social network strategies.

HEALTH EDUCATION AND HEALTH BEHAVIOR APPLICATIONS

The two interventions described next illustrate how social network and social sup­ port concepts have been applied to practice. The first intervention uses cognitive be­ havioral therapy to increase social support. The second describes a social network intervention using CHWs.

Enhancing Recovery in Coronary Heart Disease Patients Study (ENRICHD)

Observational studies have consistently demonstrated that patients with coronary heart disease (CHD) who do not have adequate social support are at higher risk for subse­ quent cardiac mortality and morbidity than are CHD patients who have supportive social networks (Lett and others, 2005). Given that CHD is the leading cause of death in the United States, the potential health benefits associated with enhancing social support for CHD patients are substantial.

:204 Health Behavior and Health Education

The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study was a multicenter, randomized trial conducted to assess the effectiveness of increas­ ing social support among CHD patients. In order to participate in the study, patients must have had a recent myocardial infarction (heart attack) and screened positive for depression or low social support. The intervention was based on the principles of cog­ nitive behavioral therapy. For the patients with low social support, a professional ther­ apist conducted a detailed assessment of the patient's social network, social skills, and problem-solving skills. Counseling sessions then addressed the specific needs identified (ENRICHD Investigators, 2001).

The intervention focused on changing the cognitions and behaviors of the pa­ tients in order to enhance their perceived social support. The intent was uot for the therapists to become long-term support providers but for them to guide the patients in efforts to enhance their own social networks. Most often, patients were encour­ aged to strengthen existing relationships rather than seek new social ties. In addi­ tion to the individual sessions, some patients (less than a third) participated in group sessions with five to eight other patients. These groups provided opportunities for the patients to exchange social support among themselves, offering both informational and emotional support. Participation in both individual and group sessions continued for six months or until the patient reported being engaged in a supportive social re­ lationship and had achieved a threshold score on a measure of perceived social sup­ port (ENRICHD Investigators, 2001).

Of the 2,481 patients who were randomized to the control (that is, usual care) or intervention groups, 39 percent were depressed, 26 percent had low perceived social support, and 34 percent met both criteria. At the six-month follow-up, among those who had been low in social support at baseline, the intervention participants experi­ enced a significantly greater increase in social support than did the usual-care-group participants. This effect was attenuated over time, but some benefit remained up to three years after baseline. Unfortunately, at no point in the four-year follow-up period did the intervention group experience fewer recurrent nonfatal myocardial infarctions nor cardiac deaths than the usual care group (ENRICHD Investigators, 2003).

However, post hoc analyses indicated that participants who were not married and did not have a significant other benefited from the intervention more than did those with partners. Furthermore, participants without a partner but who had moderate lev­ els of social support (as opposed to very low levels) available to them at baseline ben­ efited the most (Burg and others, 2005). The investigators suggest that the therapist may have served as a surrogate partner for those without a partner, whereas a cou­ ples therapy approach might have been more effective in enhancing an existing part­ ner relationship. In addition, for those without a partner and with low baseline support levels, additional opportunities to develop new supportive ties (for example, in a sup­ port group) may be necessary to achieve and maintain higher levels of support (Burg and others, 2005). Thus, conducting an assessment of the participants' social net­ works first and then matching them with an appropriate mode of intervention might have resulted in larger and more durable increases in social support. The ENRICHD investigators admit that the magnitude or the duration of the increase achieved in the

Social Networks and Social Support 205

trial may simply not have been sufficient to protect against subsequent morbidity and mortality.

Also, patients were enrolled in the study while still hospitalized due to their my­ ocardial infarction. Although negative health-related life events can be viewed as win­ dows of opportunity for health behavior change, the time immediately subsequent to a myocardial infarction might be a particularly difficult time to depend solely on the patient to bring about long-lasting changes in his or her own social network. In­ cluding other social network members in the intervention and developing a shared re­ sponsibility for increasing the exchange of support might have been more effective.

The Seattle-King County Healthy Homes Project

Asthma is the most common chronic disease of childhood, disproportionately af­ fecting low-income children and children of color (American Lung Association, 2006). Indoor air quality is a major contributor to the development and exacerbation of asthma (Institute of Medicine, 2000). The SKCHHP (Seattle-King County Healthy Homes Project) had the goal of improving the asthma-related health status of low-income children by reducing exposure to allergens and irritants in their homes. The project was developed under the auspices of Seattle Partners for Healthy Communities, with its commitment to principles of community-researcher collaboration (Krieger and others, 2002).

CHWs were recruited from the communities being served by the project. All six CHWs hired by the project lived within the targeted areas and were either personally affected by asthma or had a close family member with asthma. CHWs, because they are members of the community, have an "insider perspective"-an understanding of the culture and workings of the community (Love, Gardner, and Legion, 1997). Thus, the CHW s are perceived to have more empathic understanding (Tho its, 1995) for the community participants and to be credible sources of information and advice. Often, CHWs are hired to work in underserved, low-income areas where they provide a cul­ turally appropriate linkage between the community and the medical system or other service providers (Love, Gardner, and Legion, 1997).

The SKCHHP CHWs completed a forty-hour training that focused on knowledge and skills relevant to assessing and changing the home environment to reduce expo­ sure to asthma triggers. Once trained, the CHWs made horne visits to families who had enrolled in the project. Rather than conducting the assessments and carrying out the change strategies for the families, the CHWs provided the knowledge, re­ sources, and support necessary to empower the families to take action for themselves. The CHWs worked with each of the families to develop a Home Action Plan, based on the results of the home environment assessment, and then assisted families in car­ rying out the plans. CHWs visited the homes of participants five to nine times over the course of a year, with each visit averaging forty-five to fifty minutes (Krieger and others, 2002).

The CHWs were expected to use a caring and empathic approach with each fam­ ily. They provided instrumental, informational, and emotional support. They educated

206 Health Behavior and Health Education

the families about the various asthma triggers in the homes and how best to reduce them, assisted with some of the cleaning and repair tasks called for by the Home Ac­ tion Plan, and identified community resources that could help meet the needs of the families, whether asthma-related or not. Perhaps most important, the CHWs were at­ tentive to the concerns of each family, providing individualized advice, assistance, and encouragement. In general, participants were impressed with the efforts of the CHWs, with 84 percent of them rating their CHW s as excellent or very good (Krieger and others, 2002).

The effectiveness of the project was evaluated through a randomized trial with a one-year follow-up period. Households (n = 274) were randomly assigned to either a high-intensity intervention (the program as described earlier) or a low-intensity in­ tervention (one home visit by a CHW to assess the home environment, create an ac­ tion plan, and provide limited education and resources). After one year, the children of families in the high-intensity group had a larger decrease in the number of days with activity limited by asthma and in the number of times urgent health services were used than did the children in the low-intensity group. In addition, the children's caregivers in the high-intensity group reported more improvement in quality of life than did those in the low-intensity group. Behaviors intended to reduce asthma trig­ gers in the home also increased more among the families in the high-intensity group. Some limited data suggested that these gains in health outcomes and behaviors were sustained for at least another six months after the first follow-up (Krieger, Takara, Song, and Weaver, 2005).

FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

Both of the interventions described here illustrate the importance of tailoring social network interventions to the needs and resources of participants. No generic social net­ work intervention is likely to be effective for everyone. Thus, establishing partici­ patory assessment processes, during which individuals and communities describe the strengths and weaknesses of their social networks, will help structure programs to be optimally effective.

Social network interventions are most likely to be effective if developed and implemented within an ecological framework that considers multiple levels of influ­ ence (McLeroy, Gottlieb, and Heaney, 2001). For example, interventions that enhance individuals' motivation and skills for performing healthy behaviors while also en­ hancing the health-promoting qualities of social networks have great potential. In ad­ dition, given our growing understanding of the extent to which broad social forces (for example, crime rates and income disparities) influence the structure and func­ tion of social networks (Berkman, Glass, Brissette, and Seeman, 2000), interventions that attempt to enhance social networks within the context of community-based prob­ lem-solving efforts hold promise. Thus, an important direction for future research is to develop and evaluate social network interventions that include strategies across multiple units of practice (for example, individual, family, and community).

It is important to evaluate both intervention processes and outcomes (Israel and others, 1995). Effective social network interventions will be advanced through (I)

Social Networks and Social Support 207

carefully describing the intervention activities, (2) monitoring the effects of these ac­ tivities on the amount and quality of social support both delivered and received, and (3) assessing changes in knowledge, health behaviors, community capacity, or health status. Rigorous and comprehensive evaluation studies will improve our ability to consistently translate the health-protective effects of social networks and social support into effective interventions.

Social networks influence health and well-being in various ways, including by facil­ itating the exchange of social support. Consistent empirical evidence suggests that people who maintain strong social relationships are healthier and live longer. How­ ever, our understanding of how to enhance social networks and increase the exchange of social support among network members is just beginning. Evaluation of carefully designed and meticulously theory-informed social network interventions will help advance our ability to answer the question posed earlier: In order to effectively en­ hance the health-protective functions of social networks, who should provide what to whom (and when)?

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