Social Support and Health Promotion

 Social Network
 Social Support
 Reviewing Social Support Systems
 Social Support and Health
 Identifying Social Support Strengths and Needs
 Enhancing Social Support System

Promoting Health through Social and Environmental Change

 Health as Social Change
 Health and in a Challenging Social Environment
 Promoting Health Through Environmental Change
 Voluntary Change versus Legislative Policy
 Economic Incentives for Disease Prevention and Health Promotion

https://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml

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Companion Materials

 Part One

o Part One Overview

o Chapter One
o Chapter Two
 Part Two

o Part Two Overview

o Chapter Three
 Chapter Three Overview
 Learning Objectives
 Main Constructs
 Measuring Constructs
 Empirical Testing
 Application of Constructs
 Critiques of Model
 Quiz Questions
 Idea Library
 Glossary
o Chapter Four
 Chapter Four Overview
 Learning Objectives
 Introduction
 Chapter Outline
 Figures of TRA/TPB
 Figures of TRA/TPB Overview
 Theory of Reasoned Action
 Theory of Planned Behavior
 Integrated Behavior Model
 Measuring Constructs
 Measuring Constructs Overview
 Intention
 Attitudes
 Subjective Norms
 Perceived Behav. Control
 Scoring Direct Measur.
 Indirect Measurement
 Empirical Testing
 Application: Non-Intervent.
 Application: Intervention
 Critiques
 Quiz Questions
 Idea Library
 Glossary
o Chapter Five
 Chapter Five Overview
 Learning Objectives
 Theory Overview
 Key Constructs
 Assumptions of TTM
 Measuring Constructs
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Six
 Chapter Six Overview
 Learning Objectives
 Overview
 Key Constructs
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Seven

 Part Three

o Part Three Overview

o Chapter Eight
 Chapter Eight Overview
 Learning Objectives
 Key Constructs
 Measuring Constructs
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
o Chapter Nine
 Chapter Nine Overview
 Learning Objectives
 Key Constructs
 Key Contructs Overview
 Social Support
 Social Networks
 Conceptual Model
 Measuring Constructs
 Measuring Constructs Overview
 Social Networks
 Social Support
 Empirical Testing
 Examples
 Examples Overview
 Intervention
 Non-Intervention
 Critiques
 Quiz Questions
 Idea Library
 Glossary
o Chapter Ten
 Chapter Ten Overview
 Learning Objectives
 Theory Overview
 Key Constructs
 Key Constructs Overview
 Theoretical Extensions
 Measuring Constructs
 Applications
 Empirical Testing
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Eleven
 Chapter Eleven Overview
 Learning Objectives
 Overview
 Key Functions
 Moderators
 Empirical Review
 Examples
 Questions
 Idea Library
 Glossary
 References
o Chapter Twelve

 Part Four

o Part Four Overview

o Chapter Thirteen
 Chapter Thirteen Overview
 Learning Objectives
 Key Constructs
 Measuring Constructs
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Fourteen
 Chapter Fourteen Overview
 Learning Objectives
 Theory Overview
 Key Constructs
 Measuring Constructs
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Fifteen
 Chapter Fifteen Overview
 Learning Objectives
 Dimensions of Organizational Change
 Stage Theory of Organizational Change
 Organizational Development Theory
 Interorganizational Relations Theory
 Community Coalition Action Theory
 Empirical Testing
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Sixteen
 Chapter Sixteen Overview
 Learning Objectives
 Overview
 Dim. of Communication
 Levels of Analysis
 Individual Level Theories
 Macro Level Theories
 Meta-Analysis
 Examples
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Seventeen

 Part Five
o Part Five Overview
o Chapter Eighteen
 Chapter Eighteen Overview
 Learning Objectives
 Overview
 Phases and Methods
 Measurement
 Empirical Testing
 Examples
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Nineteen
 Chapter Nineteen Overview
 Learning Objectives
 Overview
 Key Principles
 Theory Applications
 Research
 Empirical Testing
 Examples
 Examples Overview
 Examples BCEP
 Examples CHL
 Examples RRQ
 Examples SPN
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Twenty
 Chapter Twenty Overview
 Learning Objectives
 Theory Overview
 Core Concepts
 Measuring Constructs
 Examples
 Empirical Testing
 Critiques
 Quiz Questions
 Idea Library
 Glossary
 References
o Chapter Twenty One
 Chapter Twenty One Overview
 Learning Objectives
 Frameworks
 Program Pathways
 Empirical Testing
 Examples
 Reporting Evaluations
 Quiz Questions
 Idea LIbrary
 Glossary
o Chapter Twenty Two

Learning Objectives

Website
Section User should be able to:

1. Describe four types of social support.

2. Explain hypothesized pathways in the social networks model.

What's it all about? 3. Describe social networks using characteristics of the network as a whole and
(Key Constructs) characteristics of specific relationships.

1. Describe what issues should be considered when measuring constructs.

How do I know if it works?
(Measurement) 2. Identify strengths and limitations of available measures.

Yes, but how well does it

work? 1. Evaluate evidence for social networks using information. about measurement, study
(Empirical testing) design and data analysis.

1. Explain practical application of social networks and social support in health-related

research.

Make it happen! 2. Describe how social networks and social support may differ in intervention and non-
(Examples) intervention studies.

The good, the bad & the

ugly 1. Critically evaluate the strengths and weaknesses of using social networks and social
(Critiques) support to understand health.

Key Constructs
The goal of this section is to provide a foundation for understanding relationships between social
networks and social support and health. It is important to note that "social networks and social
support" is not a single unified theory. Instead, the social networks and social support model explains
ways in which social relationships that provide different types of social support influence (or may be
influenced by) health.

The terms social network and social support describe the structure, processes, and functions of

social relationships. Attempts to explain how social networks that provide social support improve
health are "rooted in" various theoretical perspectives (such as symbolic interactionism, social
cognitive, stress and coping). Most perspectives come primarily from social psychology and sociology.
We will begin our examination of relationships between social networks and social support and health
by identifying constructs related to social networks and social support separately. Next, we will
examine hypothesized relationships between health and social networks that provide social support.

Social Support
Social support is one of the important functions of social relationships. Social support is always
intended by the sender to be helpful, thus distinguishing it from intentional negative interactions (such
as angry criticism, hassling, undermining). Social support is commonly categorized into four types of
behaviors.

Four Types of Supportive Behaviors

1. Emotional

2. Instrumental

3. Informational

4. Appraisal

The ways in which types of social support differ may best be illustrated using an example.

Example: A 39-year-old graduate student and mother of 2 young children is feeling overwhelmed after
being diagnosed with breast cancer.

Types of Social Support

Construct Definition Application

Expressions of
empathy, love, trust Close friends and family members provide hope and a
Emotional and caring listening ear

Tangible aid and Her husband decides to work from home 2 days per week to
Instrumental service baby-sit the children while she attends her chemotherapy

Doctors provide facts about breast cancer and guidance

Advice, suggestions, during the treatment process Her mother offers advice about
Informational and information her own chemotherapy treatment 3 years prior

Information that is A close friend of 15 years reminds her of all of the qualities
useful for self- that equip her to "beat" breast cancer (to encourage an
Appraisal evaluation accurate assessment of her current situation)
Social Networks
In addition to identifying and classifying social support, it can be helpful to examine the sources of
support. The term social network refers to linkages between people that may or may not provide
social support and that may serve other functions (i.e. social comparison, companionship, social
influence).

Two approaches used to explore social networks

1. Examine whole network

2. Examine specific relationships within the network

We will use the same example to show how one could describe the whole social network that
provides different types of support to the 39-year-old graduate student diagnosed with breast cancer.

Social Network (as a whole)

Construct Definition Application

Determine if entities within her network are

Extent to which network interrelated. Perhaps she is going to the same
members know & interact physician as her mother & her hair stylist who both
Density with each other had breast cancer a few years ago

Extent to which network Determine if she belongs to a diverse group of people

members are or if most or all share similar characteristics (age,
Homogeneity demographically similar race/ethnicity, marital status, etc.)

Extent to which network Determine the location (family or friend's residences,

Geographic members live in close physician's office, etc.) of those who provide her with
Dispersion proximity to focal person social support

Extent to which members of

the dyad share equal power Determine power dynamics in various relationships
Directionality and influence (i.e.- patient/provider; husband/wife)

Another way to understand how social support is provided by the social network of our 39-year-old
breast cancer patient is to examine characteristics of specific relationships between other network
members and herself.

Social Network Relationship Characteristics

 Construct Definition Application

Extent to which resources and Her husband's willingness to assume her familial
support are both given and roles while she is in treatment/recovery just as
Reciprocity received she does when he is ill or working late

Extent to which social The close emotional bonds she shares with her
relationships offer emotional husband and mother are stronger than the
Intensity/Strength closeness emotional bond she shares with her co-workers

Her close friend of 15 years is also her supervisor

at work. Consequently, her friend is able to
Extent to which social relations modify work-related responsibilities to
Complexity serve many functions accommodate her illness.

Extent to which social

relationships exist in the The relationship between herself & her physician
context of organizational or exists in the context of the patient/provider
Formality institutional roles relationship

Conceptual Model
The social networks & social support conceptual model shows how supportive connections between
people (or other entities) influence physical, mental and social health. The model consists of 5
hypothesized relationships between social networks providing social support and health.

It is important to note that the concepts discussed in the previous two sections lie in the top box
labeled "Social Networks & Social Support." Therefore, the concepts discussed earlier are used to
describe the composition of a social network and type of support provided by that network, while the
model illustrates several ways a network may influence health.
 Social Networks
Research questions or hypotheses that seek to explore how an entire social network influences health
can assess characteristics of the network's structure in many ways. This section provides examples of
instruments used to measure three commonly used characteristics that are discussed in the textbook.

Homogeneity
Density (Typically, size can be assessed using the same measure)
Geographic dispersion

Homogeneity can be measured using items that assess demographic characteristics such as age,
race/ethnicity, occupation, or marital status. Instruments may come from a wide range of sources
(questionnaires used by the census bureau or other agencies, research studies with similar aims,
generated by the researcher)

*Note: Utilizing existing instruments that have been previously tested is preferable because many
psychometric issues must be considered when creating items.
One way to measure Density is to use a Social Network List (SNL). There has been support for its
use in mental health research.

Hirsch (1980)
- Network size assessed by counting the number of significant others the focal individual lists 
- Density is determined from focal individual's judgment of which of these significant others have
relationships with each other

Geographic Dispersion can be measured using a geographic information system (GIS). GIS is a

method used to integrate, display and analyze geographic data.

For more information visit about GIS, a brief demo can be viewed at www.esri.com/what-is-gis

Researchers may also be interested in ways relationships within a social network influence health.
This section provides examples of ways two of the more commonly studied characteristics of network
relationships have been assessed.

Reciprocity
Emotional Closeness

Reciprocity can be measured several ways. Since reciprocity assesses the benefit from ties within a
network, it is closely related to social support and is often determined using social support
instruments.

One measure of reciprocity is total reciprocity. Total reciprocity describes whether, on average,
relationships within the network give as much support to the focal person as he or she provides to
other network members.

- Networks that are not approximately balanced can be described as "underbenefitting" (individual
gives more than receives), "overbenefitting" (individual receives more than gives).

- One disadvantage of this approach is the inability to recognize when a network that is reciprocal on
average contains many nonreciprocal relationships.
Two alternate approaches address the disadvantage of assessing total reciprocity by examining
relationship-specific reciprocity or support-specific reciprocity.

- Relationships-specific: Instead of using a summation of how much support is given and received,
assessing reciprocity within specific relationships can identify exactly where "underbenefitting"
or"overbenefitting" occurs.

- Support-specific: reciprocity provides more information than total reciprocity by determining the
extent to which different types of support may be able to offset one another. For example, provision of
a lot of emotional support may not balance the effects of lacking financial assistance.

Source: Tilburg, Sonderen, & Ormel, (1991). The measurement of reciprocity in ego-centered
networks of personal relationships: A comparison of various indices. Social Psychology Quarterly,
54(1), 54-66.

Emotional Closeness is typically measured by asking someone to rate their emotional relationship
with someone in the network. This can be done using a Likert scale.

For example:
"How would you describe your emotional relationship with your mother/father/closest friend/ main
partner at the time of your HIV diagnosis?" 
Responses: 1 (very distant) to 4(very close)

Source: Zea, et al. (2004). Disclosure of HIV-Positive status to Latino gay men's social networks.
American Journal of Community Psychology, 33, 107-116.

Issues that should be considered when measuring features of social networks include:

1. How network ties will be defined. Will only socially recognized roles be included? Only those with
whom the focal individual has an emotional bond? Will it be based on the exchange of resources?
2. What is the unit of analysis? A focal individual? Other units, such as families, organizations?
Future direction:
Social networks investigations may benefit from examining other characteristics of social networks,
such as directionality, complexity and formality, which have received less attention.

Sources:
Cohen, S., Underwood, L.G. & Gottlieb, B. (2000). Social Support Measurement and Intervention.
Oxford University Press: NY.Marsden, P.V. (1990). Network data and measurement. Annual Review
in Sociology (16), 435-463.

Social Support
The purpose of some investigations is to explore how different types of social support that are
provided by network members impact health. There has been widespread interest in social support.
This section provides some examples of instruments used to measure different dimensions of social
support.

The most commonly measured dimensions of social support include:

Emotional support
Instrumental support
Informational support
Important considerations include:
 1. Assessing perceived support vs. received support

2. Deciding which dimensions should be assessed given the sources of support and health topic
under investigation (Such decisions can be made based on theory, findings from the research
literature, or knowledge of the health topic).

Selecting the most appropriate instrument for a particular population and research question can be
difficult. Answering the following questions during the design phase may make the selection process
easier:

1. What supportive functions are relevant for this population?

2. Should I measure received support as well as perceived support?

3. How long a measure do I need (number of items)?

4. Should I use a composite score or separate scale scores?

5. Should I include measures of unsupportive interactions as well as support?

6. Should I assess support from specific network members?

7. Should I measure both availability and satisfaction with support?

8. Will I need to adapt the measure for a specific population or stressor?

9. Will I need to adapt the measure for an intervention study?

Source: Cohen, S., Underwood, L.G. & Gottlieb, B. (2000). Social Support Measurement and
Intervention. Oxford University Press: NY.

Future Direction:

 Explore the impact of different sources of support (i.e. healthcare provider vs. peers) not just
different types of support.
  Identify determinants of perceived support. If perceived support is in fact related to positive
health outcomes, it may be beneficial to understand how the perception of support can be
improved.

 Relationships may not be exclusively positive or negative. Future investigations may consider
the simultaneous measurement of both types of interactions from the same source.

What is Social Cognitive Theory?

Social Cognitive Theory (SCT) is an interpersonal level theory developed by Albert Bandura that
emphasizes the dynamic interaction between people (personal factors), their behavior, and their
environments.

This interaction is demonstrated by the construct called Reciprocal Determinism. As seen in the figure
below, personal factors, environmental factors, and behavior continuously interact through influencing
and being influenced by each other.

How to use Reciprocal Determinism: Consider multiple ways to change behavior; for example,
targeting both knowledge and attitudes, and also making a change in the environment.

Outcome Expectations

 Definition: Beliefs about the likelihood and value of the consequences of behavioral choices.
  Example: A study designed to determine the extent to which positive outcome expectations
and self-efficacy influence disclosure of HIV seropositivity to sexual partners examined these
outcome expectations:

o I believe my partner(s) will reject me if I tell him/her that I am HIV-positive.

o I believe that my partner(s) will not trust me if I tell him/her that I am HIV-positive.

o I fear being rejected by my sex partner(s) if I tell him/her that I am HIV positive.

Response was indicated on a 4-point scale: 4 = strongly agree, 3 = somewhat agree,

2 = somewhat disagree, 1 = strongly disagree.

 How to use it: Demonstrate positive outcomes of performing a desired behavior.

For more information: Semple SJ, Patterson TL, Shaw WS, Pedlow CT, Grant I. Disclosure of HIV
seropositivity to sexual partners: an application of Social Cognitive Theory.Behavior Therapy 1999;
30, 223-237.

Self-Efficacy

 Definition: Confidence or belief in one's ability to perform a given behavior. Self-efficacy is

task-specific, meaning that self-efficacy can increase or decrease based on the specific task
at hand, even in related areas.

 Example: A study designed to determine the extent to which positive outcome expectations
and self-efficacy influenced disclosure of HIV seropositivity to sexual partners examined these
aspects of self-efficacy [1]:

o I can bring up the topic of my HIV-positive serostatus with any sexual partner.

o I can disclose my HIV-positive serostatus to all partners before we engage in sex.

o I can handle any sexual partner's reaction to my HIV-positive serostatus disclosure.

Response was indicated on a 4-point scale: 4 = strongly agree, 3 = somewhat agree,

2 = somewhat disagree, 1 = strongly disagree.
  How to use it: Break down behavior change into small, measurable steps. Allow intervention
participants to recognize and celebrate small successes along the path to larger behavior
change.

For more information: Semple SJ, Patterson TL, Shaw WS, Pedlow CT, Grant I. Disclosure of HIV
seropositivity to sexual partners: An application of Social Cognitive Theory. Behavior Therapy 1999;
30, 223-237.

Collective Efficacy

 Definition: Confidence or belief in a group's ability to perform actions to bring about desired

change. Collective efficacy is also the willingness of community members to intervene in
order to help others.

 Example: A study designed to determine the relationship between neighborhood-level

collective efficacy and BMI in youth examined the degree to which respondents felt their
neighborhood had the following:

o Adults that kids look up to.

o People willing to help neighbors.

o Adults who watch out that kids are safe.

o People in the neighborhood who share the same values.

o A close-knit community.

o Adults who would do something if a kid did graffiti.

o Adults who would scold a kid if showing disrespect.

 How to use it: Bring people together and mobilize them to action. Develop group activities that
allow individuals to get to know each other better and increase confidence to accomplish the
desired behavior change.
For more information: Cohen DA, Finch BK, Bower A, Sastry N. Collective efficacy and obesity: The
potential influence of social factors on health. Social Science & Medicine 2006; 62, 769-778.

Self-Regulation

 Definition: Controlling oneself through self-monitoring, goal-setting, feedback, self-reward,

self-instruction, and enlistment of social support.

 Example: A study designed to explain "leisure time" physical exercise among high school
students measured self-regulation in five domains:

o goal-setting

o self-monitoring

o gaining and maintaining social support

o planning to overcome barriers

o securing reinforcements

 How to use it: Build in goal-setting activities throughout the intervention. Work with
participants to create realistic and measurable goals. Also allow time for reflection and
evaluation about success or failure in meeting goals.

For more information: Winters E, Petosa R, Charleton T. Using Social Cognitive Theory to explain
discretionary "Leisure-time" physical exercise among high school students. Journal of Adolescent
Health 2003; 32:436-442.

Facilitation/Behavioral Capability

 Definition: Providing tools, resources, or environmental changes that make new behaviors

easier to perform.

 Example: The Minnesota Smoking Prevention Program evaluated sixth grade students'

behavioral capability to resist positive images of smoking. This was more clearly defined as
 one's ability to identify, evaluate the truthfulness, and reject favorable images of smoking
presented through media and adult modeling.

 How to use it: Provide both knowledge-based training and skill-based training to intervention
participants.

For more information: Langlois M, Petosa R, Hallam J. Why do effective smoking prevention
programs work? Student changes in social cognitive theory constructs. Journal of School Health
1999; 69(8), 326-331.

Observational Learning

 Definition: Beliefs based on observing similar individuals or role models perform a new

behavior.

 Example: A church-based intervention, designed to increase physical activity and healthy

eating behaviors, ensured that the church's minister participated in walking clubs. He was
seen as a role model for other participants, because he grew up in the community and was
now a well-known leader. His involvement with the program was key to encouraging church
members to change their behavior.

 How to use it: Provide credible role models who reflect the target population and perform the
desired behavior.

For more information: Winett RA, Anderson ES, Whiteley JA, Wojcik JR, Rovniak LS, Graves KD,
Galper DI, Winett SG. Church-based health behavior programs: Using Social Cognitive Theory to
formulate interventions for at-risk populations. Applied & Preventive Psychology 1999; 8:129-142.

Incentive Motivation

 Definition: The use and misuse of rewards and punishments to modify behavior.

 Example: As part of efforts to increase mammography screening rates, a number of

studies/programs have offered cash prizes, small gifts, as well as coupons for food in
exchange for attendance at screening visits.
  How to use it: Determine what kind of incentives would motivate participants to participate in
the intervention. Offer options, as not all participants may be motivated by the same
incentives

For more information: Kane RL, Johnson PE, Town RJ, Butler M. A Structured Review of the Effect of
Economic Incentives on Consumers'Preventive Behavior. American Journal of Preventive Medicine
2004; 27:4, 327-352.

Moral Disengagement

 Definition: Ways of thinking about harmful behaviors and the people who are harmed that
make infliction of suffering acceptable by disengaging self-regulatory moral standards.

 Example: Terrorism is an example of destructive conduct which has been made personally

and socially acceptable by the terrorist who portrays their actions as serving a moral purpose.
This self-framing then allows the individual to act on a moral imperative [7].

 How to use it: Re-engage self-regulatory moral standards by illuminating possible

dehumanization and diffusion of responsibility onto others.

For more information: Bandura, A. (1990). Mechanisms of moral disengagement. In W. Reich (Ed.),
Origins of terrorism: Psychologies, ideologies, theologies, states of mind (pp. 161-191). Cambridge:
Cambridge University Press.
References:

 Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health
education: Theory, research, and practice. San Francisco, CA: Jossey-Bass.

https://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml

Wang, H.-H., Wu, S.-Z., & Liu, Y.-Y. (2003). Association Between Social Support
and Health Outcomes: A Meta-analysis. The Kaohsiung Journal of Medical
Sciences, 19(7), 345–350.doi:10.1016/s1607-551x(09)70436-x