Social Support and Cardiovascular Disease

Social Support and Cardiovascular Disease

THE PLENUM SERIES IN BEHAVIORAL PSYCHOPHYSIOLOGY AND MEDICINE Series Editor: William J. Ray Pennsylvania State University University Park, Pennsylvania Recent volumes in the series: BIOLOGICAL BARRIERS IN BEHAVIORAL MEDICINE Edited by Wolfgang Linden CARDIOVASCULAR REACTIVITY AND STRESS J. Rick Turner CLINICAL APPLIED PSYCHOPHYSIOLOGY Edited by John G. Carlson, A. Ronald Seifert, and Niels Birbaumer ELECTRODERMAL ACTIVITY Wolfram Boucsein HANDBOOK OF RESEARCH METHODS IN CARDIOVASCULAR BEHAVIORAL MEDICINE Edited by Neil Schneiderman, Stephen M. Weiss, and Peter G. Kaufmann INTERNATIONAL PERSPECTNES ON SELF-REGULATION AND HEALTH Edited by John G. Carlson and A. Ronald Seifert THE PHYSIOLOGY OF PSYCHOLOGICAL DISORDERS: Schizophrenia, Depression, Anxiety, and Substance Abuse James G. Hollandsworth, Jr. THE PSYCHOLOGY AND PHYSIOLOGY OF BREATHING: In Behavioral Medicine, Clinical Psychology, and Psychiatry Robert Fried with Joseph Grimaldi SOCIAL SUPPORT AND CARDIOVASCULAR DISEASE Edited by Sally A. Shumaker and Susan M. Czajkowski A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment For further information please contact the publisher.

Social Support and Cardiovascular Disease Edited by Sally A. Shumaker Wake Forest University Winston-Salem, North Carolina and Susan M. Czajkowski National Heart, Lung, and Blood Institute Bethesda, MRryland Springer Science+Business Media, LLC

Library of Congress Cataloging-1n-Publication Data Social support and cardiovascular disease / edited by Sally A. Shumaker and Susan M. Czajkowski. p. cm. (The Plenum series in behavioral psychophysio1ogy and medicine) Includes bibliographical references and index. ISBN 978-1-4899-2574-9 1. Cardiovascular system Diseases Social aspects. 2. Cardiovascular system Diseases Psychological aspects. 1. Shumaker, Sally A. II. Czajkowski, Susan M. III. Series. [DNLM: 1. Cardiovascular Diseases epidemiology. 2. Cardiovascular Diseases etiology. 3. Cardiovascular Diseases- -rehabi1itation. 4. Social Environment. WG 100 S6783 1993] RA645.C34S67 1993 362.1'961 dc20 DNLM/DLC for Library of Congress 93-20980 CIP ISBN 978-1-4899-2574-9 DOI 10.1007/978-1-4899-2572-5 ISBN 978-1-4899-2572-5 (ebook) Springer Science+Business Media New York 1994 Originally published by Plenum Press, New York in 1994 Softcover reprint of the hardcover 1st edition 1994 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

To our parents, Lottie and VerI Shumaker and Agnes and Joseph Czajkowski, who taught us the value of social support

Contributors Terrence L. Amick, Donahue Institute for Governmental Services, University of Massachusetts, Amherst, Massachusetts 01003 Toni C. Antonucci, Institute for Social Research, University of Michigan, Ann Arbor, Michigan 48106 Sheldon Cohen, Department of Psychology, Carnegie-Mellon University, Pittsburgh, Pennsylvania 15213 Susan M. Czajkowski, Behavioral Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892 Dennis M. Davidson, University of California, San Francisco, School of Medicine, Cardiology Division, San Francisco General Hospital, San Francisco, California 94110 Kathleen Dracup, School of Nursing, University of California, Los Angeles, Los Angeles, California 90024 William W. Dressler, Department of Behavioral and Community Medicine, University of Alabama School of Medicine, Tuscaloosa, Alabama 35487 Christine Dunkel-Schetter, Department of Psychology, University of California, Los Angeles, Los Angeles, California 90024-1563 Kathleen Ell, School of Social Work, Hamovitch Social Research Center, University of Southern California, Los Angeles, California 90089-0411 Michael J. Follick, Institute for Behavioral Medicine, Cranston, Rhode Island 02920 vii

viii CONTRIBUTORS Larry Gorkin, Institute for Behavioral Medicine, Cranston, Rhode Island 02920 Ellen M. Hall, Division of Behavioral Sciences and Health Education, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland 21205 Helen P. Hazuda, Division of Clinical Epidemiology, Department of Medicine, University of Texas Health Science Center, San Antonio, Texas 78284-7873 Ernest H. Johnson, Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia 30310-1495 Jeffrey V. Johnson, Division of Behavioral Sciences and Health Education, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland 21205 Jay R. Kaplan, Bowman Gray School of Medicine, Wake Forest University, Wmston-Salem, North Carolina 27157-1040 Robert M. Kaplan, Division of Health Care Sciences, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California 92093-0622 Wendy Kliewer, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia 23284 Stephen B. Manuck, Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania 15260 Raynwnd Niaura, Division of Behavioral Medicine, Miriam Hospital, Providence, Rhode Island 02906 Judith K. Ockene, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical Center, Worcester, Massachusetts 01605 Kristina Orth-Gomer, National Institute for Psychosocial Factors and Health, 171 77 Stockholm, Sweden Barbara R. Sarason, Department of Psychology, University of Washington, Seattle, Washington 98195 Irwin G. Sarason, Department of Psychology, University of Washington, Seattle, Washington 98195

CONTRIBUTORS ix Sally A. Shumaker, Department of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina 27103 Carol K. Whalen, Department of Psychology and Social Behavior, School of Social Ecology, University of California, Irvine, Irvine, California 92717 Dianne L. Wilkin, Institute for Behavioral Medicine, Cranston, Rhode Island 02920

Preface The hypothesis that health can be affected by supportive interactions with individuals within one's social network has now been confirmed by a wealth of evidence that implicates the social environment in health status generally and in cardiovascular disease (CVO) risk specifically. The evidence includes an extensive epidemiological literature on the relationship between various measures of social support and morbidity, as well as allcause and disease-specific mortality. This book represents an effort to examine comprehensively the existing research and theory in the area of social support and CVD and suggest priorities for future research. It is an outgrowth of the discussions and recommendations that took place at a working conference cosponsored by the National Heart, Lung, and Blood Institute and the University of California at Irvine, where a multidisciplinary group of researchers convened for several days to review critically the available evidence linking social support to CVO etiology, occurrence, and rehabilitation. Following a brief overview of some of the key concepts discussed in this book, we present some important issues to consider when examining the relationship of social support to disease, and we conclude with a synopsis of the individual chapters and considerations for future research in this area. The term social support has been used to describe both the structure of a person's social environment and the resources (or functions) such environments provide. Structure includes the size, density, complexity, symmetry, and stability of an individual's family, fr ends, coworkers, and health professionals and community resources; it j 5 usually referred to as one's "social network." The functional component of social support is defined as an individual's perception of the availability of support and of the resources provided, and it is labeled "social support"; however, the term social support is often used to describe both the structural and functional aspects of the social environment (e.g., the resources provided xi

xii PREFACE in a supportive exchange among network members; see Shumaker & Brownell,1984). In order to understand the role support plays in CVD, it is important to distinguish between various structures and functions of the social environment and to specify how each structure or function might increase or decrease the risk of CVD. A variety of measures have been used to assess social support from both a structural and functional perspective. Structural measures include items such as marital status, number and frequency of contacts with family and close friends, church membership, and involvement in community and other groups. Functional measures most often involve the perceived availability and quality of support. An example of a structural approach to the measurement of social support is the Social Activities Questionnaire (Donald & Ware, 1982), which contains 11 self-administered items that assess the number of supportive contacts available to and actually used by an individual. An example of a functional support measure, the Inventory of Socially Supportive Behaviors (Barrera, S a n d& lramsey, e ~ 1981) is a 40-item self-administered scale that focuses on the number and type of helping transactions received by an individual within a specific period of time. Another example of a functional measure of support is the Social Support Questionnaire (Sarason, Levine, Basham, & Sarason, 1983). This measure assesses both the perceived availability of and satisfaction with a number of functional aspects of support (e.g., informational support, tangible aid). Several issues should be taken into account when developing models of the social support-cvd relationship. In terms of measurement, the viability of a given model depends on the measure used to assess social support; for example, a model suggesting that social support influences behavioral risk should use a definition of support that taps its social influence potential (e.g., social integration). A model proposing that support protects persons from the pathogenic influences of stress must operationalize support so as to reflect the availability of resources that aid in stress evaluation and coping (e.g., perceived availability of stress-reducing resources). The emphasis is on measures that are logically linked to proposed pathogenic processes. Support-disease models can be classified in terms of whether the relationship between social support and disease represents a main effect or a stress-buffering effect. Main effect models suggest that support directly influences the pathogenic process irrespective of the level of stress a person is experiencing. In contrast, buffering models suggest that support affects health by decreasing the risks created by psychosocial stressors; thus it is effective only when a person is stressed (see Cohen & Wills, 1985). The definition and measure of support used influences the appropriateness of

PREFACE xiii a main effect versus stress-buffering model. For example, there is evidence from the literature on psychological disorders that main effects are associated with a structural measure or the number of different roles a person has (social integration) and that buffering effects occur only when perceived availability of stress-buffering resources are assessed (Cohen & Wills, 1985; Kessler & McLeod, 1985). The stability of the support characteristic under consideration is also an important issue in developing models of the relationship between support and CVD. Because atherosclerosis is a disease that develops over a long period of time, conceptions of social support that are stable over such periods make more sense in this context than conceptions that vary considerably over time. Also, the mechanisms proposed in models of support and CVD may be more or less important depending on the stage in the pathogenesis of the disease. For example, support-induced increases in neuroendocrine response may be more important for persons with severe atherosclerosis than for persons with minimal occlusion. Finally, some of the proposed models allow for relationships between support and disease outcomes other than CVD. For example, a model may propose that support results in decreases (or, under some conditions, increases) in behaviors that put individuals at risk for CVD (e.g., smoking, poor diet, poor exercise habits). Because these behaviors are also risk factors for diseases other than CVD (e.g., cancer), such a model would be somewhat nonspecific in that regard. Similarly, models proposing that the neuroendocrine changes that may result from social support lead to the development of CVD also lack specificity, because these neuroendocrine changes may also suppress immune function and result in increased risk of infectious diseases and cancer. Each of these issues is discussed in detail in this volume. The chapters in the first section address key concepts in social support and CVD; these chapters provide a basis for further discussion of the relationship between social support and CVD. In Chapter 1, Davidson presents a brief introduction to CVD, discussing the epidemiology, etiology, primary prevention, treatment, and prognosis for various cardiovascular disorders. Next, focusing on conceptual and methodological issues with regard to social support itself, Antonucci and Johnson overview concepts and methods used in social support research, and Sarason and Sarason provide a critical review of specific measures of support. Finally, Kaplan focuses on conceptual and operational aspects of health outcomes, another element in social support research. His chapter provides an overview of health status measures used in this area, as well as an elaboration of the decision theory approach to health status assessment. Chapters in the second section focus on the empirical evidence for a

xiv PREFACE relationship between social support and CVD. Orth-Gomer reviews the international epidemiological evidence for an association between social support and CVD, whereas Hazuda provides a critical evaluation of studies conducted in the United States. In the following section, two chapters consider the individual, environmental, and cultural aspects of the relationship between social support and CVD. Johnson and Hall discuss the relationship of workplace social support to CVD and Dressler presents a cross-cultural perspective on the support-cvd relationship. The last two sections address the role of social support in CVD etiology, progression, treatment, and recovery. Cohen, Kaplan, and Manuck describe models of the social support-cvd process and discuss potential psychological and biological underlying mechanisms. Whalen and Kliewer then present a developmental perspective, discussing social influences during childhood and adolescence that affect CVD risk. Finally, using Prochaska's stages-of-change model, Amick and Ockene consider the role of social support in modifying risk factors for CVD. In the final section, Gorkin, Follick, Wilkin, and Niaura review the evidence on the role of social support in CVD progression and treatment; Ell and Dunkel Schetter present a review of research regarding social support during recovery from CVD; and Dracup discusses the relationship of social support to recovery and compliance within the context of formal CVD rehabilitation programs. Thus this volume provides perspectives from the psychological, sociological, and medical communities in a critical review of the evidence linking social support to CVD. In addition to reviewing the relevant empirical and theoretical research, the chapters underscore a number of gaps in the literature and provide insights for the future direction of research in this area. Several key points are summarized below: Researchers need to identify the relative importance of different dimensions of social support (e.g., structural versus functional aspects of support) in the etiology of CVD, in CVD risk factors, and during the crisis and rehabilitative phases of CVD. The mechanisms through which social support affects the development of, occurrence of, and recovery from CVD should be examined. Research is severely limited on the influence of social support in the development of risk factors for CVD during childhood and adolescence. The influence of individual-difference variables (e.g., personality characteristics, hostility, coronary-prone behavior, social class), and environmental factors (e.g., control within work setting, economic

PREFACE xv context) on the social support-cvd relationship warrants further exploration. The differential impact of social support on CVD at critical stages or transitions in life (e.g., marriage, death of spouse) need to be assessed. Research is needed that addresses the effects of 'Stress on the social support-cvd relationship, especially in the development of risk factors. The process through which information concerning health is exchanged among support network members should be examined (e.g., sources of information exchanged, accuracy of information, effects of attitudinal similarity on health issues among network members, response of members to behavior change attempts, how resistance is encountered). The factors affecting the activation of social support in a crisis situation and the maintenance of this support over time need to be identified. Research is needed to explore the effects of social support on helpseeking behavior, decision making regarding treatment, immediate adjustment to a cardiovascular event, the adoption of and adherence to behaviors designed to reduce risk, and in maximizing recovery and rehabilitation of individuals experiencing a major cardiac event. The effects of the CVD process on social support and social networks should be considered. Researchers should focus on the ways interventions using social support can be designed to influence the impact of the CVD process on the individual and family members. Researchers are just beginning to examine the role of social support systems in CVD etiology, incidence, and recovery. The empirical evidence reviewed in the volume-along with several untested but promising theoretical leads-suggest that social networks and social support may playa critical role in CVD. Only through future research, however, will we be able to understand what characteristics of the social environment are involved, how they influence the disease process, and under what conditions these effects occur. References Barrera, M. J., Sandler, I. N., & Ramsey, T. B. (1981). Preliminary development of a scale of social support: Studies of college students. American Journal of Community Psychology, 9, 435-447.

xvi PREFACE Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357. Donald, C. A., & Ware, J. E., Jr. (1982). The quantification of social contacts and resources. Santa Monica, CA: RAND Corporation. Kessler, R. c., & McLeod, J. D. (1985). Social support and mental health in community samples. In S. Cohen & S. L. Syme (Eds.), Social support and health. New York: Academic Press. Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support: The Social Support Questionnaire. Journal of Personality and Social Psychology, 44, 127-139. Shumaker, S. A., & Brownell, A. (1984). Toward a theory of social support: Closing conceptual gaps. Journal of Social Issues, 40, 11-36.

Contents I. KEY CONCEPTS 1. An Introduction to Cardiovascular Disease Dennis M. Davidson Hypertension... 3 Coronary Artery Disease (CAD)... 6 Cardiac Dysrhythmias and Sudden Death... 12 Cerebrovascular Disease... 14 Conclusion... 15 References... 16 3 2. Conceptualization and Methods in Social Support Theory and Research as Related to Cardiovascular Disease......... 21 Toni C. Antonucci and Ernest H. Johnson Concepts and Measures in the Study of Social Support...... 22 Social Support and Cardiovascular Disease................. 25 Methodological Issues and Future Research Agenda... 34 Summary and Conclusions... 35 References... 36 3. Assessment of Social Support... 41 Barbara R. Sarason and Irwin G. Sarason Origins of Social Support Research........................ 42 Current Assessment Approaches as a Function of Their Origins... 43 xvii

xviii CONTENTS Psychometric Qualities of Measures and Research Outcomes 49 Relationship among Social Support Instruments... 54 What Should Govern the Choice of a Social Support Measure 57 References... 60 4. Measures of Health Outcome in Social Support Research... 65 Robert M. Kaplan The Conceptualization and Measurement of Social Support 66 Measurement of Health Status... 68 Measurement Issues... 76 Summary... 90 References... 91 II. ESTABLISHING A RELATIONSHIP BETWEEN SOCIAL SUPPORT AND CARDIOVASCULAR DISEASE 5. International Epidemiological Evidence for a Relationship between Social Support and Cardiovascular Disease... 97 Kristina Orth-Gomb Longitudinal Studies of General Population Samples... 102 Cross-Sectional Studies of General Population Samples...... 107 Longitudinal Studies of Patient Populations... 110 Evidence from Intervention Studies... 112 Summary... 116 References... 116 6. A Critical Evaluation of U.S. Epidemiological Evidence and Ethnic Variation... 119 Helen P. Hazuda IHD Risk Factors... 120 IHD Morbidity... 124 IHD Mortality... 131 Survival Following Acute IHD Episodes... 137 Summary and Recommendations... 140 References... 141

CONTENTS xix III. INDIVIDUAL, ENVIRONMENTAL, AND CULTURAL FACTORS IN SOCIAL SUPPORT AND CARDIOVASCULAR DISEASE 7. Social Support in the Work Environment and Cardiovascular Disease... 145 Jeffrey V. Johnson and Ellen M. Hall Work Support and Cardiovascular Disease... 146 Theoretical Frameworks Linking Work, Social Support, and Health... 148 Substantive and Methodological Questions... 156 Determinants of Collectivity and Social Support... 157 Intervention in the Workplace: Formation of Autonomous Work Groups... 161 The Changing Nature of Work and the Labor Force... 162 References... 163 8. Cross-Cultural Differences and Social Influences in Social Support and Cardiovascular Disease William W. Dressler The Epidemiological Transition... 169 Social Structure and Social Change... 172 Modernization and Cardiovascular Disease................. 175 Cross-Cultural Studies of Social Support................... 179 Discussion... 186 References... 190 167 IV. THE DEVELOPMENT OF CARDIOVASCULAR DISEASE 9. Social Support and Coronary Heart Disease: Underlying Psychological and Biological Mechanisms................. 195 Sheldon Cohen, Jay R. Kaplan, and Stephen B. Manuck Differentiating Social Support............................. 196 Differentiating Stages of CHD... 197 Research Suggesting a Link between Social Support and the Etiology of Physical Disease... 199 Psychosocial Models Linking Social Support to CHD... 202

xx CONTENTS Biological Models Linking Social Support to CHD... 206 Discussion and Summary....................... 214 References... 216 10. Social Influences on the Development of Cardiovascular Risk during Childhood and Adolescence.................. 223 Carol K. Whalen and Wendy Kliewer Cardiovascular Risk during Childhood and Adolescence: The Case for Concern.................................. 223 Social Influences on Cardiovascular Risk in Youths... 227 Preventing Program-Generated Problems: Emanations and Antidotes... 240 Summary and Conclusion...................... 249 References... 251 11. The Role of Social Support in the Modification of Risk Factors for Cardiovascular Disease... 259 Terrence L. Amick and Judith K. Ockene Social Support... 260 Modification of Behavior... 261 Precontemplation Stage... 268 Contemplation Stage..................................... 269 Action Stage... 271 Maintenance and Relapse Stages... 272 Conclusion... 274 References... 275 V. THE CRISIS AND REHABILITATION PHASES OF CARDIOVASCULAR DISEASE 12. Social Support and the Progression and Treatment of Cardiovascular Disease... 281 Larry Gorkin, Michael J. Follick, Dianne L. Wilkin, and Raymond Niaura Symptomatic Cardiovascular Disease Effects on Patient and Support System... 282

CONTENTS xxi Infrahuman Investigations................................ 285 Human Evidence........................................ 287 Directions for Future Research............................ 294 References... 296 13. Social Support and Adjustment to Myocardial Infarction, Angioplasty, and Coronary Artery Bypass Surgery... 301 Kathleen Ell and Christine Dunkel-Schetter Overview... 301 Research on Early Psychological Adjustment... 306 Social Support during Acute Coronary Events.............. 308 Intervention Research... 312 Research Agenda... 319 References... 322 14. Cardiac Rehabilitation: The Role of Social Support in Recovery and Compliance... 333 Kathleen Dracup The Need for Cardiac Rehabilitation Programs... 334 Cardiac Rehabilitation... 335 Social Support and Cardiac Rehabilitation.................. 338 The Dark Side of Social Support... 347 Summary and Recommendations... 348 References... 350 Index... 355