SOCIAL SUPPORT

Research on social support and social relationships among older adults—and their correlates and consequences—is voluminous and growing. The beneficial effect of social support on individual well-being is one of the most consistent findings in this literature. In summarizing the importance of social relations to successful aging, John W. Rowe and Robert L. Kahn (1998) drew four conclusions:

• A lack of social ties is a risk factor for poor health
• Social support in various forms can have direct positive effects on health
• Receipt of social support can buffer some of the negative effects of health declines associated with aging
• The type of social support found to be effective varies by individual needs and situations

Conceptualizing social support and social integration

Although sometimes used interchangeably with terms such as social integration, social networks, or social relationships, a narrower definition of social support is also common. In that narrower usage, social support refers to social interaction in which the actions of one party are intended to benefit another party. Thus, though social support may be seen as one aspect of other, broader terms, it is differentiated in part by its focus on the provider’s intentions and the potential benefits to the recipient.

No clear consensus exists regarding definitions of the other descriptors of social interaction, but, in general, the following distinctions are made. Social integration denotes the existence, quantity, and/or breadth of social ties. Synonyms are social connectedness and social embeddedness. A lack of social integration has been labeled social isolation. Social network refers to the entire structure of an individual’s social relationships and the connections among them. A network may be described in multiple ways, such as its homogeneity (similarity among members) or density (ties among all members). Social relationships and social ties are broad, general terms that refer to an individual’s connections to others.

While social integration, social isolation, and social networks primarily refer to the structure of an individual’s relationships, the concept of social support is used to denote possible functions of those relationships. Much of the research examining the association of social relationships to well-being has been limited to measures of social integration or isolation. In interpreting the usually positive effects of integration on well-being, some researchers have suggested that integration is, in part, a proxy for social support. Thus, it is necessary to discuss social integration and social isolation in conjunction with social support. Although social support specifically focuses on the positive side of social interaction, the other terms (integration, networks, and relationships) include consideration of the negative side of interaction (e.g., conflict or excessive demands). Research on the potential costs of social relationships is more limited and is not addressed here.

Measures of social integration capture information about the quantity and variety of social ties maintained by an individual. To assess quantity of ties, seniors may be asked how many people they interact with on a regular basis or how many people to whom they feel close ties. Variety of ties addresses how many different social roles an individual occupies, including spouse, parent, grandparent, sibling, friend, neighbor, employee, volunteer, church member, organization member, and others.

Possible functions of relationships are also identified in measures of social support. As noted, the provision of social support in a relationship refers to actions taken by one party to assist or benefit another party. Several aspects of the interaction may be of interest, including:

• The type of support provided
• The quantity, timing, and/or frequency of support provided
• Whether the support was actually received or simply is perceived as available
• The recipient’s satisfaction with the level of support provided or available
• The relationship between the parties involved
• Whether or not the support has been or will be reciprocated

The types of social support fall into five general categories. Instrumental support refers to tangible items, such as financial assistance, goods, or services. For example, a disabled older person may receive meals or help with housework. To quantify instrumental support, studies have collected data on the dollar value of money or goods transferred and on hours of time given in services during a given time period. A simpler approach is to ask whether or not the amount transferred within the time period exceeded a specific level (e.g., $200 in the past twelve months). Emotional support includes provision of love, caring, sympathy, and other positive feelings. Appraisal support includes feedback given to individuals to assist them in self-evaluation or in appraising a situation. Informational support refers to helpful advice, information, and suggestions. For example, a senior may ask a friend’s opinion regarding which doctor to see. Companionship support refers to the presence of others with whom to participate in meaningful or enjoyable activities. Companionship is considered to provide the individual with a sense of belonging to a group. Differentiating among the intangible types of support (emotional, appraisal, informational, and companionship) can be difficult, as can quantifying the level of support provided. Collection of information typically is limited to whether or not the specific type of support was provided during the specified time period and, perhaps, the frequency with which the support was provided.

Some researchers have suggested that the quantity of support received is less important to well-being than the individual’s perception that support is available if needed. This distinction between received and perceived support has proven valuable in clarifying how social relations influence well-being. Received support appears to be more important in the face of specific problems or stressors, whereas perceived support seems to be of ongoing benefit. Measures of perceived support include questions regarding whether or not the senior has someone in whom to confide, someone to provide emotional support, or someone to provide caregiving should the need arise.

The relationship between the support provider and recipient is also relevant, as suggested by some popular gerontological models. In 1979, Marjorie Cantor proposed the hierarchical compensatory model, in which older individuals exhibit a hierarchy of preferences regarding who should provide support. A spouse typically is the first choice, followed by adult children; other kin, friends, and neighbors; and, finally, formal service providers. Who actually provides support to an older person needing assistance depends upon the availability, proximity, and emotional closeness of individuals in the person’s network, as well as on cultural norms.

Another important determinant is the older person’s level and types of needs; the more disabled an older person is, the more likely he or she is to rely on formal providers, particularly for instrumental support. The task-specific model, developed by Eugene Litwak (1985), takes account of both the older individual’s specific needs and the characteristics of the potential helpers. The model posits that the group or person most likely to be preferred as a support provider will be the one best suited to manage the necessary tasks. The model matches tasks to providers according to the following structural dimensions: proximity, length of commitment, commonality of lifestyle, group size, sources of motivation, division of labor, and level of technical knowledge. Litwak and colleagues have argued that the hierarchical-compensatory model is simply a special case of the task-specific model.

The hierarchical-compensatory model and the task-specific model primarily focus on provision of instrumental support and emphasize the distinction between informal and formal care. Informal care is defined as unpaid assistance provided to needy seniors. Family, friends, and neighbors represent informal sources of care and often provide aid with such tasks as light housekeeping, food shopping, meal preparation, and transportation. Formal sources of care include a range of services, from Meals-on-Wheels to home health care visitors, from adult day care to nursing home care. The more disabled an older person becomes, the more likely he or she is to rely on formal care providers.

The convoy model of social relations, proposed by Robert L. Kahn and Toni C. Antonucci, offers a broader view of social ties in old age. This model also incorporates the notion of a hierarchy of relationships in personal networks, but it bases this hierarchy on emotional closeness. The convoy model uses a life-span perspective; thus the focus on convoys as opposed to networks. The concept of the convoy captures the dynamic aspects of social ties, taking account of qualitative changes at the level of the individual, the dyad, and the network, as well as changes in network membership. Cause-and-effect relations are also an important part of the model. Because relationships unfold over time, past interactions influence future interactions. For example, past receipt of emotional support from a friend will predispose an individual to assist that friend in the future. Reciprocity in relations is viewed as the ideal and is positively related to well-being.

Benefits of social support and social integration

Rowe and Kahn identify active engagement with life as one of the key components of successful aging, along with avoiding disease and maintaining high cognitive and physical function. They view these three components as intertwined, with high performance in any one area enabling higher performance in the others. Research on the benefits of social support and social integration suggests that social relationships can contribute to all three components.

John Cassel and Sidney Cobb have been credited with stimulating the flood of research on social support and health that began in the 1970s. In separate review articles, both men argued that social relationships appeared to be protective of health. The early evidence, however, primarily was cross-sectional, and thus unable to establish causation. It was unclear whether strong social ties protect health (social causation hypothesis), or whether individuals in poor health are unable to maintain strong social ties (social selection hypothesis).

In the late 1970s and early 1980s, prospective mortality studies from several community epidemiologic surveys were published and provided evidence for the social causation hypothesis. James House and colleagues reviewed this evidence in a 1988 Science magazine article. They concluded that low levels of social integration represented a ‘‘cause or risk factor of mortality, and probably morbidity, from a wide range of diseases.’’

Subsequent research has replicated and expanded on these findings by examining a variety of health outcomes in different populations. Further, researchers have attempted to elucidate the mechanisms linking social ties and health by developing more sophisticated measures of social relationships and testing more elaborate models.

The vast amount of research conducted on the relationship between social relationships and health in middle and old age has produced some mixed results, but it is possible to draw some generalizations.

Mortality. Low levels of social integration place individuals at higher mortality risk. Researchers have considered whether this relationship represents a threshold or gradient effect. In other words, is there a minimum number of social ties necessary to receive the health benefit (threshold effect)? Or, does the risk of mortality lessen with each increase in the number of ties (gradient effect)? Some evidence supports the threshold model, but the issue is not resolved. Fewer mortality studies have examined specific measures of social support, but there is limited evidence of an association between support and mortality.

Onset of physical disease. Few studies have produced evidence of an influence of social integration or social support on the development of physical disease.

Progression of and recovery from physical disease. Receipt of emotional support (and perhaps other forms of intangible support) contributes to physical health by slowing the progression of chronic disease and aiding in recovery from other physical ailments. Studies have examined conditions such as post–myocardial infarction, stroke, arthritis, different cancers, hip fractures, and extremity injuries from falls.

Emotional or mental health. Both social integration and social support are important for the maintenance of emotional health. Low levels of integration and support place seniors at heightened risk for depression, anxiety, and psychological distress. Social isolation and lack of emotional support are particularly strong predictors of emotional health problems. Perceived quality of life and positive affect are enhanced by social integration and reciprocal support networks.

Functional health Various aspects of social integration reduce the risks of developing physical disabilities (difficulty performing activities of daily living) and experiencing cognitive declines.

Why do social integration and social support promote health? Despite the vast number of studies, there is no clear answer to this question. The diversity of findings suggest, however, that there are several different mechanisms. The operative mechanism likely depends on the characteristics of the individual, his or her social situation, and the health condition of interest. Proposed mechanisms include the following:

• Provision of health-enhancing material resources and services
• Reduction of the perceived severity of stressors
• Reduction in the occurrence of stressors
• Improved coping skills and assistance with coping
• Promotion of positive health behaviors (social control or social influence model)
• Increased social bonding and attachment
• Stronger sense of coherence and self-esteem

Differentials in social support and social integration

One stereotype of old age says that it is a time of loneliness and isolation, a time characterized by the loss of social ties when adult children leave home, seniors retire, and peers and spouses die. Although this portrait is certainly true for some older people, the majority of seniors appear to keep active social ties. Rowe and Kahn invoke the concept of convoys of social support to describe the way in which individuals maintain supportive networks into old age. Whereas seniors do experience losses to their networks over time, they replace many losses with new ties. In fact, network size appears to be fairly stable across the life course, with, on average, eight to eleven members in personal networks. Compared to the networks of younger adults, seniors’ networks tend to include more kin and, perhaps, be less proximate. Thus, the number of close social ties declines only modestly with age, while the types of ties change.

This picture of the typical senior, however, can mask important variations in social support and integration. The structure and function of social ties appears to vary by gender, marital status, race and ethnicity, socioeconomic status, and residence in rural, urban, or suburban areas.

Gender differences in social support and social integration have been one of the most consistent research findings. In general, women have markedly higher levels of social interaction than do men. Women provide and receive more social support, exchange a greater variety of types of support, and have larger numbers of social ties. Men, however, may benefit more than women from the support they receive. In other words, the health benefits of social ties appear to be greater for older men than for older women. Support provided through the marital relationship seems to be an important part of this gender difference. Older women are more likely to be widowed, and thus without the emotional support of a spouse. Further, however, men receive more health benefits from marital support than do women.

Evidence regarding racial and ethnic group differentials in social ties is mixed. Seniors from all groups tend to maintain active networks, both giving and receiving support. Most seniors also benefit from frequent involvement with church and family. The composition of social networks, however, differs across groups. Compared to white seniors, African Americans and Mexican Americans include more extended family members in their personal networks. Minority seniors are also more likely to rely exclusively on family members and close friends for instrumental assistance, whereas older whites use more formal support providers.

Knowledge about social network differences across socioeconomic status (SES) groups is limited. In general, evidence suggests that higher-SES individuals have more support available, provide more support, and include more friends in their networks. Providing emotional support to others has been associated with higher self-esteem—with the association being strongest for upper-SES seniors. Group differences in involvement with family are minimal. It is not clear to what extent SES differences in social ties are confounded with racial and ethnic group differences.

Place of residence also has some influence on social ties. Elderly urban-dwellers are more likely to use formal care providers and have more diverse personal networks than rural seniors. In contrast, older rural residents report a higher proportion of family members in their networks. Older residents of poor and deteriorating urban neighborhoods have smaller networks and less emotional support. Differences in availability of contacts and support may explain some of these differences.

Laura Rudkin Ivonne-Marie Indrikovs

See also Caregiving, Informal; Family; Friendship; Health, Social Factors; Religion; Sibling Relationships.

BIBLIOGRAPHY

Angel, R. J., and Angel, J. L. Who Will Care for Us? Aging and Long-Term Care in Multicultural America. New York: New York University Press, 1997.

Antonucci, T. C., and Akiyama, H. ‘‘Social Support and the Maintenance of Competence.’’ In Societal Mechanisms for Maintaining Competence in Old Age. Edited by S. L. Willis, K. W. Schaie, and M. Hayward. New York: Springer Publishing, 1997. Pages 182–206.

Berkman, L. F. ‘‘The Role of Social Relations in Health Promotion.’’ Psychosomatic Medicine 57(1995): 245–254.

Berkman, L. F., and Glass, T. ‘‘Social Integration, Social Networks, Social Support, and Health.’’ In Social Epidemiology. Edited by L. F. Berkman and I. Kawachi. New York: Oxford University Press, 2000. Pages 137–173.

Berkman, L. F.; Glass, T.; Brissette, I.; and Seeman, T. E. ‘‘From Social Integration to Health: Durkheim in the New Millenium.’’ Social Science & Medicine 51 (2000): 843–857.

Bowling, A. Measuring Health: A Review of Quality of Life Measurement Scales, 2d ed. Philadelphia: Open University Press, 1997.

Cantor, M. H. ‘‘Neighbors and Friends: An Overlooked Resource in the Informal Support System.’’ Research on Aging 1 (1979): 434–463.

Cohen, S.; Underwood, L. G.; and Gottlieb, B. Social Support Measurement and Intervention: A Guide for Health and Social Scientists. New York: Oxford University Press, 2000.

Cohen, S., and Wills, T. A. ‘‘Stress, Social Support, and the Buffering Hypothesis.’’ Psychological Bulletin 98 (1985): 310–357.

Heaney, C. A., and Israel, B. A. ‘‘Social Networks and Social Support.’’ In Health Behavior and Health Education: Theory, Research, and Practice, 2d ed. Edited by K. Glanz, F. M. Lewis, and B. K. Rimer. San Francisco: Jossey-Bass Publishers, 1997. Pages 179–205.

House, J. S.; Landis, K. R.; and Umberson, D. ‘‘Social Relationships and Health.’’ Science 241 (1988): 540–545.

House, J. S.; Umberson, D.; and Landis, K. R. ‘‘Structures and Processes of Social Support.’’ Annual Review of Sociology 14 (1988): 293–318.

Krause, N. ‘‘Issues of Measurement and Analysis in Studies of Social Support, Aging and Health.’’ In Aging, Stress, and Health. Edited by K. S. Markides and C. L. Cooper. New York: John Wiley & Sons, 1989. Pages 43–66.

Litwak, E. Helping the Elderly: The Complementary Roles of Informal Networks and Formal Systems. New York: The Guilford Press, 1985.

McDowell, I., and Newell, C. Measuring Health: A Guide to Ratings Scales and Questionnaires, 2nd ed. New York: Oxford University Press, 1996.

Messeri, P.; Silverstein, M.; and Litwak, E. ‘‘Choosing Optimal Support Groups: A Review and Reformulation.’’ Journal of Health and Social Behavior 34 (1993): 122–137.

Pillemer, K.; Moen, P.; Wethington, E.; and Glasgow, N. Social Integration in the Second Half of Life. Baltimore: Johns Hopkins University Press, 2000.

Rowe, J. W., and Kahn, R.L. Successful Aging. New York: Pantheon Books, 1998.

Seeman, T. E. ‘‘How Do Others Get under Our Skin? Social Relationships and Health.’’ In Emotion, Social Relationships, and Health. Edited by C. D. Ryff and Burton H. Singer. New York: Oxford University Press, 2001. Pages 189–210.

Seeman, T. E. ‘‘Social Ties and Health: The Benefits of Social Integration.’’ Annals of Epidemiology 6 (1996): 442–451.

Wills, T. A., and Fegan, M. F. ‘‘Social Networks and Social Support.’’ In Health Psychology. Edited by A. Baum, T. A. Revenson, and J. E. Singer. Mahwah, N.J.: Lawrence Erlbaum Associates, 2001. Pages 209–234.