Background

Social support often refers to resources or functions that are provided by an individual’s social contacts, including family members, friends, coworkers, neighbors, and other significant persons in the individual’s life. These functions may include emotional support, material support (e.g., provision of money or food), instrumental support (performance or assistance with normal role functions), and informational support (provision of advice or information), and others. Alternatively, other definitions of social support focus primarily on the structure of an individual’s social network (the presence and interconnectedness of social relationships); support is therefore implicit in the nature of the individual’s social structure. There is no consensus regarding the definition of social support, however, and working definitions vary in scope, focus, and applicability to different types of research.¹

Research conducted over the past several decades has yielded an abundant literature on the relationship between social support and health states. Social support has been associated with mortality,² as well as health-related parameters including cardiovascular, endocrine, and immune function (for review, see ref 3). Marital status, a measure of social support in itself, was associated with in-hospital mortality among surgical patients and length of stay among both medical and surgical inpatients.⁴ Higher levels of social support have predicted better treatment adherence and self-care among people with diabetes,⁵ depression,⁶ and alcoholism.⁷

Many researchers have used the "stress-buffering" hypothesis⁸ as a conceptual framework when studying the relationship between social support and health. The stress-buffering hypothesis states that social support moderates an individual’s emotional, behavioral, and physiological reactions to stressful life events, thereby reducing the impact of stress on health. Other putative mechanisms of social support's effects on health include a positive influence on the individual’s psychological resilience, and direct influences on health in the absence of stress or other mediating processes.⁹

VA Relevance

Social support may be interpreted as both a cause and a consequence of health-related phenomena relevant to the veteran population. Low social support has been identified as a risk factor for posttraumatic stress disorder (PTSD),^10-12 depression,^10,12,13 anxiety,¹⁰ and poorer general health¹² among veterans. The relationship between social support and health status is not likely to be unidirectional; although evidence from these studies suggests that low social support may be a vulnerability, it is also worthwhile to consider the long-term effects of chronic illness on the maintenance of social support.¹⁴

Research on social support also has implications for health care utilization among veterans. A study of 123 elderly veteran men discharged from medical/surgical hospitals found that social isolation substantially increased the risk of rehospitalization within one year.¹⁵ Research conducted among Australian veterans of the Vietnam War also found an association of social support with health care utilization.¹⁶

Measurement

Social support is typically assessed using self-report and interview methods. The large volume of research on social support across multiple fields of study (e.g., psychology, medicine, sociology) has generated numerous and often vague definitions of the construct, reflected in the wide range of social support questionnaires that currently exist. A number of instruments were developed in response to a research question that necessitated more detailed measurement of some aspect of social support, rather than a complete reconceptualization of the construct.

The reliability and validity of social support measures vary considerably (for review, see ref 17,18). There is no clear consensus or "gold standard" assessment method for measuring social support, and there are no objective criteria by which to validate new social support measures. Thus, the meaning of social support is itself constructed from the process of measurement.

Several published measures of social support have shown robust psychometric properties and are in wide use. However, social support instruments are heterogeneous in focus, differing (if not exclusive) in their emphasis on the structure of the social network ("structural support", e.g.¹⁹), the characteristics of support that has actually been given to the respondent ("received support", e.g.²⁰), and the respondent’s belief that support is available in times of need ("perceived support", e.g.²¹). Measurement of these vdifferent domains of social support may have distinct challenges. For instance, "structural" support measures may be more reliable than perceived support measures, but validity may be compromised if the respondents’ social ties are inconsistent with their perceptions of being supported. Some authors have suggested that structural support, received support, and perceived support actually represent distinct constructs.^1,22 However, several instruments have incorporated multiple aspects of social support (e.g., the Social Support Questionnaire, reviewed below).

Because many social support instruments were developed using college student samples, generalizability to non-student populations should be considered. Few social support scales have been validated for use among ethnic minority populations.²³ Although there are few disease-specific social support instruments, particular types of social support may have special significance in certain clinical populations.²⁴

Through literature review, METRIC identified three commonly used self-report instruments for measuring social support. These are ranked according to number of citations, as determined by the ISI Web of Knowledge.²⁵ What follows is a brief summary of each instrument and three applicable references.

Most Frequently Cited Instruments

1. Social Support Questionnaire (SSQ)
   [793 Citations]
2. Perceived Social Support (PSS) Scales
   [548 Citations]
3. Interpersonal Support Evaluation List (ISEL)
   [537 Citations]

1. Lakey B, Cohen S. Social support theory and measurement. In Coehn S, Underwood L, Gottlieb BH, Social Support Measurement and Intervention: A Guide for Health and Social Scientists (pp. 29-52). New York: Oxford University Press; 2000.
2. Berkman LF, Syme SL. Social networks, host resistance and mortality: a nine-year follow-up study of Alameda County Residents. Am J Epidemiol 1979;109:186-204. [Abstract]
3. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK. The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. Psych Bull 1996;119:488-531. [Abstract]
4. Gordon HS, Rosenthal GE. Impact of marital status on outcomes in hospitalized patients: evidence from an academic medical center. Arch Int Med 1995;155:2465-2471. [Abstract]
5. Wen LK, Parchman ML, Shepherd MD. Family support and diet barriers among older Hispanic adults with type 2 diabetes. Fam Med 2004;36:423-430. [Abstract]
6. Voils CL, Steffens DC, Flint EP, Bosworth HB. Social support and locus of control as predictors of adherence to antidepressant medication in an elderly population. Am J Geriatr Psychiatry 2005;31:157-165. [Abstract]
7. Humphreys K, Moos RH, Cohen C. Social and community resources and long-term recovery from treated and untreated alcoholism. J Stud Alcohol 1997;58:231-238. [Abstract]
8. Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psych Bull 1985;98:310-357. [Abstract]
9. Cohen S, Gottlieb BH, Underwood LG. Social relationships and health. In Cohen S, Underwood LG, Gottlieb BH (Eds), Social Support Measurement and Intervention. New York: Oxford University Press; 2000.
10. Boscarino JA. Posttraumatic stress and associated disorders among Vietnam veterans: the significance of combat exposure and social support. J Trauma Stress 1995;8:317-336. [Abstract]
11. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748-766. [Abstract]
12. Ren XS, Skinner K, Lee A, Kazis L. Social support, social selection and self-assessed health status: results from the Veterans Health Study in the United States. Soc Sci Med 1999;48:1721-1734. [Abstract]
13. Koenig HG, Meador KG, Shelp F, Goli V, Cogen HJ, Blazer DG. Major depressive disorder in hospitalized medically ill patients: an examination of young and elderly male veterans. J Am Geriatr Soc 1991; [Abstract]39:881-890.
14. Moos RH, Cronkite RC, Moos BS. Family and extrafamily resources and the 10-year course of treated depression. J Abnorm Psychol 1998;107:450-460. [Abstract]
15. Mistry R, Rosansky J, McGuire J, McDermott C, Jarvik L. Social isolation predicts re-hospitalization in a group of older American veterans enrolled in the UPBEAT Program. Int J Geriatr Psychiatry 2001;16(10):950-9. [Abstract]
16. Marshall RP, Jorm AF, Grayson DA, O'Toole BI. Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans. Psychiatr Serv 1998;49:1609-1611. [Abstract]
17. Heitzmann CA, Kaplan RM. Assessment of methods for measuring social support. Health Psychol 1988;7:75-109. [Abstract]
18. Vaux A. Assessment of social support. In Veiel HOF, Baumann U, The Meaning and Measurement of Social Support (pp. 193-216). Bristol, PA: Hemisphere Publishing Corporation; 1992.
19. Brugha TS, Weich S, Singleton N, et al. Primary group size, social support, gender and future mental health status in a prospective study of people living in private households throughout Great Britain. Psychol Med 2005;35:705-714. [Abstract]
20. Barrera M, Sandler IN, Ramsay TB. Preliminary development of a scale of social support: studies on college students. Am J Community Psychol 1981;9:435-447.
21. Procidano ME, Heller K. Measures of perceived social support from friends and from family: three validation studies. Am J Community Psychol 1983;11:1-24. [Abstract]
22. McDowell I, Newell C. Measuring Health. 2nd ed. New York: Oxford University Press; 1996.
23. Mutran EJ, Reed PS, Sudha S. Social support: clarifying the construct with applications for minority populations. J Ment Health Aging 2001;7:67-78.
24. Abraído-Lanza, AF. Social support and psychological adjustment among Latinas with arthritis: a test of a theoretical model. Ann Behav Med 2004;27:162-171. [Abstract]
25. ISI Web of Knowledge, Accessed November 2005. Available: http://isi01.isiknowledge.com/portal.cgi/wos/.