Social support is defined as help in difficult life situations

Social support is a concept that is generally understood in an intuitive sense, as the help from other people in a difficult life situation. One of the first definitions was put forward by Cobb (Cobb, 1976). He defined social support as ‘the individual belief that one is cared for and loved, esteemed and valued, and belongs to a network of communication and mutual obligations’. In the MINDFUL project social support is defined as ‘the perceived availability of people whom the individual trusts and who make one feel cared for and valued as a person’ (MINDFUL, 2008). This definition is connected to the Oslo-3 Social Support Scale (OSS-3), which is included in the ECHI short list as the indicator of social support. This indicator was proposed by the MINDFUL project.

A distinction exists between perceived and provided support

A distinction can be made between perceived and provided social support. Most studies are based on the measurement of subjectively perceived support, whereas others aim at measuring social support in a more objective sense. The definition in terms of a subjective feeling of support raises the question whether social support reflects a personality trait, rather than the actual social environment (Pierce et al., 1997; Sarason et al., 1986). Most researchers will agree that the person as well as the situation affects perceived social support, and that the concept deals with the interaction between individual and social variables.

Various types of social support possible

Types and sources of social support may vary. House (House, 1981) has described four main categories of social support: emotional, appraisal, informational and instrumental.

• Emotional support generally comes from family and close friends and is the most commonly recognized form of social support. It includes empathy, concern, caring, love, and trust.
• Appraisal support involves transmission of information in the form of affirmation, feedback and social comparison. This information is often evaluative and can come from family, friends, co-workers, or community sources.
• Informational support includes advice, suggestions, or directives that assist the person to respond to personal or situational demands.
• Instrumental support is the most concrete direct form of social support, encompassing help in the form of money, time, in-kind assistance, and other explicit interventions on the person’s behalf.

Social support is closely related to the concept of a social network

Social support is closely related to the concept of a social network, or the ties to family, friends, neighbors, colleagues, and others of significance to the person. Within this context, social support is the potential of the network to provide help. However, the social network may also be the cause of psychological problems. The interplay between social support, the social network, and psychological health is presented by Halle and Wellman in a model: The social network as a mediating construct. This model shows that social support can be seen as resulting from certain characteristics of the social network, which are in turn caused by environmental and personal factors. The social network, through social support, may affect health in different ways: by affecting the level of negative life events and other stressors, by affecting how stressful a person experiences his or her situation and copes with it, and/or by directly affecting health (this is further explained in consequences for health). The model suggests that it is important to distinguish between the structural and quantitative aspects of the social network on the one side, and social support on the other (see also: O'Reilly, 1988).

Social integration refers to supportive relationships within the community

Whereas the concept of social support mainly refers to the individual and group level, the concept of social integration can refer to the community level (Berkman & Glass, 2000). A well integrated community refers to well developed supportive relationships between people in the community, with everybody feeling accepted and included. A related concept is social capital, which is often used as the sum of supportive relationships in the community. Social capital may, however, also be used in a somewhat different meaning, such as solidarity (Kawachi & Berkman, 2000).

Relevance for public health

It is important for public health policy to collect information on social support in the population to enable risk assessment and the planning of preventive interventions at different levels. Reliable and valid instruments exist for monitoring social support, which are recommended for use in population surveys.

Instrument for measuring social support

There is a great number of instruments measuring social support, but many of them have low or unknown validity and reliability (O'Reilly, 1988). For a selection of instruments assessing social networks and social support see Berkman & Glass, 2000.

The Oslo-3 Social Support Scale (OSS-3), was included in the ECHI shortlist as the indicator of social support, following a recommendation by the MINDFUL project. This scale has high predictive validity with respect to anxiety and depression, as well as positive mental health, and has been effectively used as a survey instrument in different countries (Korkeila et al., 2007; Melzer, 2003). The OSS-3 is a three-item scored rating scale that has been developed on the basis of a number of community surveys in Norway. These surveys investigated the association between social support and psychological distress. Out of 12 questions on support from family, friends and neighbors, three questions were selected because of high correlations with psychological distress. They cover different aspects of social support (Dalgard et al., 2006a):

• number of persons to count on;
• other peoples’ interests; and
• help from neighbors.

The Oslo-3 Social Support Scale describes three items; the questions, the response categories, and the corresponding scores.

The level of social support differs between European countries

The level of social support differs between European countries as shown in Percentage of people with poor social support in the EU, as measured by the OSS-3. The highest percentages of poor support are reported in Italy, France, Belgium, Greece and Finland, whereas the lowest percentages are found in Sweden, Ireland, Northern Ireland, Spain and Denmark. These differences could be caused by translation bias, that is, bias in giving exactly the same meaning to the same questions in different cultures. However, the differences could also reflect real differences in social support. Countries with the highest level of social support (i.e. Sweden and Ireland) tend to report the lowest levels of psychological distress and vice versa (EORG, 2003a). It is unknown what elements of social support are responsible for the differences between the countries.

In contrast, another survey, EUROHIS (Meltzer, 2003) showed only slight variations between countries. A likely explanation of this discrepancy is that EUROHIS reported mean scores, whereas the Eurobarometer reported percentage distribution of those with poor support. A country with the highest percentage of poor social support does not necessarily have the lowest mean score on social support. Another explanation of the small differences in the EUROHIS study may be that it is mainly limited to Eastern European countries, whereas the Eurobarometer covers a wider geographical range. Anyhow, from a health point of view the percentage receiving poor support is of greatest interest.

Women experience more social support than men

In a survey of five European countries using the Oslo-3 Social Support Scale, women reported more social support than men (Dalgard et al., 2006a), see Social support (OSS-3) by country and gender. A possible explanation of this is that women have a more socially oriented lifestyle than men: they are more focused on establishing social contacts and get more emotionally involved in other people. Their emotional involvement also seems to have negative consequences: women also reported more social network problems than men. The higher support for women was related to ‘people to count on’ (‘confidents’) and ‘peoples’ interests’ (‘concern’) in all countries except Spain. The OSS-3 item ‘help from neighbors’ showed less stable gender relations. For both genders, Spain was among the highest scorers for all items, whereas the lowest scores were recorded in Finland.

Social support has direct and indirect effects

With respect to health, social support may have a direct or indirect (buffer) effects (Cohen & Syme, 1985).

• The direct effect implies that social support has a positive effect on health, irrespective of life situation.
• The buffering effect occurs only when the person is exposed to stressors, like negative life events and more lasting adversities. In this instance, social support is supposed to help the person to better cope with the situation, and hence prevent stress. Coping also depends on personal characteristics, and the interplay between social support and personality assets may be crucial for the health effect of stressors.

Social support affects health through different pathways

Social support can affect a person’s health through different pathways: health behavioral, psychological and physiological pathways (Berkman & Glass, 2000).

• In the health behavioral pathway social support influences a person’s health behaviour. A lack of social support is, for example, associated with smoking, an unhealthy diet and a lack of exercise.
• In the psychological pathway social support affects health through such factors like self esteem and self-efficacy. The perception of support and positive interest from others likely induces self-confidence and optimism, which will strengthen the coping abilities of the person.
• The physiological pathway deals with various physiological stress reactions affecting among other things the immune system and cardiovascular reactions. Social support is considered to reduce stress by the strengthening of coping abilities.

Poor social support is associated with mental health problems

A large number of studies suggest that poor social support is associated with mental health problems, such as depression (e.g. Brown & Harris, 1978, House, 1981, Schaefer et al., 1981, Dalgard et al., 1995a). In a survey of seventeen EU countries, a lower level of social support (measured by the OSS-3) was strongly associated with an enhanced prevalence of psychological distress: Association between social support and psychological distress. This was observed for all three items of the OSS-3. In all of the countries the percentage of people reporting psychological distress decreased as the social support increased; the strength of the association was highly significant in 14 of the 17 countries (EORG, 2003a).

Strong social support is associated with positive mental health

A significant association between strong social support and positive mental health was found, using the Energy and Vitality Index of the SF-36 Health Survey Instrument (EORG, 2003a): Age-adjusted EVI-means by perceived social support. The relationship between social support OSS-3 and positive mental health was the same in all participating countries (Lehtinen et al., 2005).

Poor social support is also associated with mortality

Poor social support is associated with higher mortality rates (e.g. House et al., 1982, Berkman & Syme, 1979, Hansson et al., 1989, Dalgard & Haaheim, 1998). For mortality caused by cardiovascular diseases the association is especially strong (Eriksen, 1994). An overview of studies showing increased mortality associated with a lack of social support and weak social ties is given by Quick et al., 1996. However, it is difficult to untangle the effect of social support from the possible effect of personality factors, since personality factors are seldom included in the studies of social support and mortality (Eriksen, 1994).

Social support is determined by individual and social factors

Social support is a consequence of the interplay between individual factors and the social environment. Therefore, factors threatening social support may be individual or social, or both.

Social support may be partly determined by genetic factors

Social support in adulthood may be to some extent genetically determined (Bergman et al., 1990). However, the strength of this assumed relationship differs between studies. Bergman and colleagues found that genetic factors were responsible for 30% of the variance in perceived support. However, genetics made little contribution to individual differences in the actual quantity of enacted support. Furthermore, another study demonstrated only a minor role of genetic factors in the association between perceived support and depression (Kessler et al., 1994b). In this study, depression was not so much reduced by genetic determinants of social support, but mainly by the stress-buffering effect of perceived support.

Personality characteristics affect social support

Personality factors that might be associated with perceived social support are ‘interpersonal trust’ (Rotter, 1967) and ‘social phobia’ (Barlow, 1988). Without trusting other people, it is less likely that the person will perceive support from others, and interact with others in such a way that social support is provided. People with social phobia have a strong feeling of anxiety connected to contact with other people. They are afraid of being the centre of attention, and they are concerned about not giving the impression of being stupid. For these reasons they try to avoid other people as much as possible.

Social position affects received social support

The position of a person within the social structure will influence the probability of them receiving social support. The position of a person is determined by such factors as:

• Marital status: People who are not married and live alone are less likely to receive social support than people who are married or cohabitate.
• Family size: People with many children are likely to receive more social support than people with few children (Broadhead et al., 1983), because they have a more extensive family network.
• Age: Elderly people tend to receive less social support than younger people (Stephens et al., 1978).
• Gender: Women tend to receive more social support than men (MacFarlene et al., 1981).
• Socio-economic status and migration: People with lower socio-economic status and non-western immigrants report less social support than other people (Dalgard et al., 2006b; Dalgard et al., 2007b). Social support seems to decrease the lower the occupational status, unskilled workers reporting the poorest social support (Marmot et al., 1991).

For more information about the socio-economic determinants of health see the section Socio-economic factors and the EUphocus Health inequalities.

Social context determines social support opportunities

The occurrence of social support depends on the opportunities that a person creates to interact with other people. These opportunities are determined by a number of contextual variables, such as (Schieflo, 1992):

• The existence and availability of social arenas i.e. places where people can meet, like shopping centres, parks, sport arenas and the like.
• Purpose of social interaction. Without a unifying purpose for contact (e.g. addressing a common problem, playing a game, celebrating an event), social interaction will be low.
• Time spent together. Without enough time, interpersonal relationships will not develop.
• Continuity of relationships. Without continuity social relationships will easily be disrupted.
• Sharing of social norms and values. If people are too different with respect to social characteristics (such as religious and cultural preferences), it is less likely that they will develop supportive relationships.

Community structure influences social support

The structure of the community determines to what extent people live in a social context that is conducive to social support. In communities characterized by social disintegration, the level of social support among people is reduced compared to integrated communities (Leighton, 1959; Dalgard, 1986). Typical for disintegrated communities is that the level of social cohesion is low, that people lack trust in each other, and that social interaction is low.

Three types of preventive interventions: universal, selective or indicated

Preventive interventions aimed at stimulating social support can be distinguished into three types, depending on the group of people they are aimed at: universal, selective or indicated. Universal prevention consists of interventions directed at the whole population, regardless of their risk status of developing a mental disorder. Selective prevention is directed at individuals or groups with an increased risk of developing a mental disorder. Indicated prevention is targeted toward persons who have some symptoms of a mental disorder, but do not meet the diagnostic criteria for a full-blown mental disorder.

Promoting social support: an example of universal prevention

Examples of universal prevention are community projects aimed at strengthening social networks and promoting social support in specific areas. The ultimate goal of these interventions is to promote mental health. Examples of such universal interventions are the Stirling County study (Leighton, 1965) and the Eastlake study (Halpern, 1995). In the Stirling County study a community development program was implemented in a socially disintegrated community. The purpose was to strengthen social cohesion and improve social conditions by collective action (i.e. providing more jobs and stimulating the economy), under the guidance of professionals. In the Eastlake study the aim was to improve the social conditions in a poorly functioning and unsafe neighbourhood. Also here, there was active participation of the inhabitants, under professional leadership. In both these projects the mental health of the population improved significantly, as did the social interaction and cohesion.

People with stressful life-events target group for selective prevention

Selective prevention programs aim to:

• provide social support for people who have been exposed to stressful life events; and
• reduce social isolation in specific groups.

Examples of such programs are social support groups and self-help groups. Both programs aim at promoting mutual support between group members who usually share a problem such as bereavement, divorce, somatic illness or simply loneliness. The programs differ in leadership: social support groups have professional leaders, while self-help groups generally have leaders without formal training. However, the latter often do have assistance from professionals. Both program types have shown effectiveness in promoting mental health (Klytta & Wilz, 2007). Their effectiveness was demonstrated in an extensive review of social support provision to isolated elderly people. This review indicated that group activities with an educational or support input were more effective than interventions providing individual support, advice, information or health-needs assessment (Cattan et al., 2005).

Social support is one element of crisis intervention

Some interventions do include an element of social support even though they are not exclusively aimed at providing social support. An example is the so-called ‘crisis intervention’, an intervention dealing with the emotional reactions of people to disasters and traumatic events. This intervention often includes an important element of social support, in mobilizing support from the network of the victim (Weisæth, 2000)

Social skills training improves interpersonal relationships

In addition to social support groups and self-help groups, another type of intervention to stimulate social support is social skills training. Social skills training aims at helping the individual to improve his relationship with other people, and through this to increase his access to social support. An important part of the training is to improve the client’s understanding of social norms (e.g. in relation to intimacy) and to explain the importance of directing more attention to others. This would lead to the provision of more positive reinforcement for those who offer social support. Target groups can be subgroups from the general population, such as schools, as well as patient groups with special problems in interpersonal contact, such as schizophrenics (Smith et al., 1996).

Social support is often an element of indicated prevention programs

Indicated prevention programs aim to reduce the risk of people who already have symptoms of psychological stress from developing a mental disorder. Often, such (group-oriented) programs contain an element of social skills training, focusing on how to activate and improve social relations. A meta-analysis of a specific group of indicated prevention programs, the Coping with Depression Courses, demonstrated that these courses are effective in preventing unipolar depression (Kühner, 2003). Another example of indicated prevention is a group program for relatively socially isolated, middle-aged women living in a new urban neighbourhood. The women were selected based on the presence of symptoms of psychological distress. They were stimulated through various group activities and showed significant improvement in mental health together with strengthened social networks (Dalgard et al., 1995b).

Social support can be aimed at consequences of a mental disorder

Interventions to improve social support are also available for psychiatric patients and their families. These interventions are not aimed at preventing a mental disorder, but at living with the consequences of a mental disorder. A comprehensive overview of different types of social support interventions for psychiatric patients and their families is provided by Milne (Milne, 1999). These types of interventions can aim to establish supportive relationships between volunteers and patients, through for example befriending programs (Harris et al., 1999b), or to provide social support to carers, such as family carers who help their elderly relatives with dementia to stay in their own home. In the case of family carers the social support is aimed at strengthening the coping ability of the family member in a stressful life situation, and hence may prevent mental health problems in the carer (McKee et al., 1997). Support programs can also include the facilitatation of mutual social support within the family. Examples of this include family support (Atkinson & Coia, 1995), couple support (Cutrona, 1996), and parent support programmes (Asscher, 2005).

Mental Health in the EU

Health inequalities

Education

Employment

Poverty, income distribution

Occupation

Eurobarometer Public Opinion Analysis sector of the European Commission

MINDFUL Mental Health Information and Determinants for the European Level

MHE Mental Health Europe

EDF European Disability Forum

Inclusion Europe Respect, Solidarity, Inclusion for People with Intellectual Disabilities

WFMH World Federation for Mental Health

MINDFUL Mental Health Information and Determinants for the European Level

ProMenPol Promoting and Protecting Mental Health

EMHPA A European Platform for Mental Health Promotion and Mental Disorder Prevention

EPREMED European Policy Information Research for Mental Disorders

EAAD II European Alliance Against Depression II

SUPPORT Support for European Platform on Mental Health

CAMHEE Child and Adolescent mental health in enlarged European Union

Percentage of men and women with poor social support in a number of countries

Social support by country and gender

Association between social support and psychological distress

Age-adjusted EVI means by perceived social support

Author: Dalgard OS (Folkehelseinstituttet, Oslo, Norway)

Editor: Meijer S (RIVM, Bilthoven, the Netherlands)

Reviewer: -